388618_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
828) 258-8496
Area code Phone number
2. WELL INFORMATION: G /�
WELL CONSTRUCTION PERMIT# 1J I ,261 - dO'���/ ' 1
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(If amicable)
3 WELL USE (Check Applicable Box) Residenbal Water Supply
DATE DRILLED /OIT /D
TIME COMPLETED IO i 3D AM PM Q
4. WELL LOCATION: ��11�
CITY R(/ (k)i EW COUNTY AMCOM b-
e wvc CP e ReiGGA
(Street Name, Numbers Community Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC l LAND ING (check appropriate box)
❑ Slope ❑ VaNey ofitit D Ridge ❑Other
LATITUDE 36 35°5 3 ' ?QD " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 t r 1i " DMS OR 7x x o0txxxxx DD
latrtudeAowe source PS [(Topographic map
(ocabon of *ell must be shown on a USGS topo map andattached to
this form If not using GPS)
.OWNS
nta�n Srd�� hem
rName
° I
5 Z7
d
City or T State Zip Code
°'7 a1Qa
Area code Phone number
t Address ////
SY>f21//UG
6 WELL DETAILS' /
a TOTAL DEPTH* YQ S
b DOES WELL REPLACE EXISTING WELL? YES 0 NO 1:17-
c WATER LEVEL Below Top of Casing 20 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT Above Land Surface*
'Top of casing terminated aUor below land surface may require
a vananoe in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) /0 METHOD OF TEST Blowing —Rig
f. DISINFECTION. Type Chlorine Amount 2— Vn Z-
g. WATER ZONES (depth)
Top Bottom 2 90 Top Bottom
Top Bottom 34) Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING. Depth Diameter Weight Material
Top v Bottom SO Fth,XS 2/6, S AzcsD 22
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete
Top Bottom Ft
Top Bottom Ft
Method
Gravity —Flow
9. SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft. in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK*
Depth
Top Bottom
Top
Top
Ft
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom
cis
YS / SO
Si9 / di0S
/
/
/
12 REMARKS
Size Material
Fommabon Descnption
Hatt
$y41.04 t. e
Dcl<
( _'� —
—RECEIVED
Nnv - S /UIU
Information Processing uni'
DWUIt3UG
ELC
Inns162R11
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
SIGNATU
PRINTED
CE ELL ONTRACTOR DA`
R IFIED`W
r
AME OF PER1SON/L%CO STRUCTING 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-1 a
Rev 11/08