388606_Well Construction - GW1_20101108

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2 0 2 8 -A
1. WELL CONTRACTOR.
Bobby W. Potts
Well Contractor (Individual) Name
Ferguson's Well and Pump, LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester, NC
28748
City or Town State Zip Code
( 8 2 8 ) 258-8496
Area code Phone number
2. WELL INFORMATION.
WELL CONSTRUCTION PERMIT# (,()e-1-26/tomOTHER ASSOCIATED PERMIT#(rt applicable)
SITE WELL ID #(ir appicab e)
3 WELL USE (Check Applicable Box) Residenbal Water Supply
DATE DRILLED /2 //i t)
TIME COMPLETED (eo Z) AM O PM
4. WELL LOCATIONy
CITY ii / -/C!i' COUNTY Ain (,DM be
6nX �/{ /t0
(Street Name Numbers ommunity, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check approprurte box)
❑Slope ❑Valley❑Flat ORIdge OOther
LATITUDE 36 35 "2Q'i542 7 / " DMS OR 3X.XXX)(XXXXX DD
LONGITUDE 7510Z ° Z7 ' 3 /5' " DMS OR 7X XXXX)W(XX DD
Labtude/Iongltude source s Qropographic map
(location of well must be shown on a USGS topo map andetteched to
this form If not using GPS)
5. WELL OWNER
r Name
Address
/t° r /VC_ .78 %/�•
City or Town State Zip Code
(go 7- 9wfl g
Area code Phone number
6 WELL DETAILS' r
a TOTAL DEPTH' 2-r s
b DOES WELL REPLACE EXISTING WELL? YES O _NO2/
c WATER LEVEL Below Top of Casing Z() FT
(Use "t" If Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) 30 METHOD OF TEST Blowing -Rig
f. DISINFECTION. Type Chlorine Amount /6 D Z
7. CASINO. Depth
Top D Bottom
3SS606
g. WATER ZONES (depth)
Top Bottom % *VD Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Diameter Weight Material
i-$ Ft 4,%5 2/6. %» P1tc.5a2Z1
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter
Top Bottom Ft in
Top Bottom Ft. in
Top Bottom Ft in
10. SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
O /_L_
/ 3 S
31( / ,zy.c
/F ,C
lAN * Q? fur
/
12
REMARKS
Size
Method
Gravity -Flow
Slot Size Material
m
In
In
Material
Forrnabon Descnption
Play
c944)auk
V�Vtali 71.
-
int�RrtiOVyu13Or= nQ Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNA
TRACTOR ;11D E
PRIN D NAMrOF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone]
Form GW-la
Rev 11/08