388619_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:
WELL CONSTRUCTION PERMIT* Rio - (90 sro
OTHER ASSOCIATED PERMIT/Kit applicable)
SITE WELL ID r(lf appliabe)
3 WELL USE (Check Applicable Box) Resldenbal Water Supply
DATE DRILLED /° `24 /0
TIME COMPLETED /1. i O AM L PM p
4. WELL LOCATION.
CITY iic1LO�r Vi ✓ COUNTY JAve600,4
4/ (. p.After 5 Cove, ,&i.
(Street Name Numbers, Community Subdivision, Lot No Paroel, Zip Code)
TOPOGRAPHIC�/ LAND SETTING (check appropriate box)
D lope ❑Valley ❑ Flat ❑Ridge ❑Other
LATITUDE 36 •,?/ ' 4 2 7 " DMS OR 3x XX)00(XXXX DD
LONGITUDE 75 " S/o 15*1- ' " DMS OR 7x XX)00XXXX DO
Latitude/longitude source 1201/�S DTopographic map
(location of well must be shown on a USGS topo map endaltached to
this tom; if not using GPS)
5. WEL
OWNER
/ to la l'a �V
/ q rrn S �
Street Address
/01(/ss- ante_, PA -
City or Town
Oa) 371- Soy /
Area code Phone number
6 WELL DETAILS*
a TOTAL DEPTH. /
b DOES WELL REPLACE EXISTING WELL? YES 0 NO E
c WATER LEVEL Below Top of Casing /Q ° FT
(Use "+" 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), METHOD OF TEST B1OWing-Rig
f. DISINFECTION Type Chlorine Amount trot,
$'7b
State Zip Code
g. WATER ZONES (depth)
Top 3 70 Bottom Top Bottom
Top I/ rd.' Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom rl Ft
Top Bottom Ft
Top Bottom Ft
Thickness/
Diameter Weight
(,.A21". d19ge:
8 GROUT Depth
Top 0 Bottom 20 Ft
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth
Top Bottom Ft in in
Top Bottom Ft. in in
Top Bottom Ft in in
Material
v1/C
Material Method
Concrete Gravity -Flow
Diameter Slot Sloe Material
10 SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
o / %7
v / d-c
45 L / roa--
/
/
/
/
/
12 REMARKS
Size Material
Formabon Descnptlon
C/v
14/1
JAN tii 2O1
NO - S 2910
RfOr"'t"nn Prnraccint) IInit
DWQ/BOG
1 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 OW , R
SI
PRIN
CONTRACTOR
/O-ll-/o
DATE
s C. 1 1 • ,
W t
NAME OF 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. (919) 8074300
Form GW-la
Rev 11/08