388620_Well Construction - GW1_20101108

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma 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 Q
WELL CONSTRUCTION PERMITS tkJ f-+ ai�� D�6�/i l
OTHER ASSOCIATED PERMIT#K(if applicable)
SITE WELL ID p(tt applicable)
3 WELL USE (Check Applicable Box) Residenbal Water Supply p/
DATE DRILLED id(X iD
TIME COMPLETED I 3 0 AM 6M ❑
4. WELL LOCATION. /�
CITY Car f' J l to �A) COUNTY gtOAC6 A4
OS brash�l< i2- Q
(Street Name Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAN TTING (cheek appropnate box)
❑ Sipe ❑ Valley lid ❑Ridge ❑ Other
LATITUDE 363 S oit ' 7 ` 1 • DMS OR 3x.xxxxxxxxX DD
LONGITUDE 75f3,X • 625 ' S r " DMS OR 7x xx ocxxxx ( DD
Latrtudellongttude source PS OTopographic map
(loeabon of tsell must be shown on a USGS topo map andsttached to
this Ibrm Unot using GPS)
5 WE OWNER
., n,e. /4onn tk
Owner Name
/, 5 zezts,k C,eE -Dal
t Address
, e� fir '73
Cdy or Town State Zip Code
( y
.8i ! 78• 7.3I
Area code Phone number
6 WELL DETAILS'
a. TOTAL DEPTH'
LID S
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
YES 0 NO ❑ •
(Use `+" if Above Top of Casing) O
d. TOP OF CASINO 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). 7 METHOD OF TEST Blowing -Rig
f. DISINFECTION. Type Chlorine Amount 1.*D 2—
FT
g. WATER ZONES (depth)
Top Bottom 2.1.0 Top Bottom
Top Bottom 3 7.5 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING. Depth Diameter Weight
Top D Bottom 94 Ft Alag1 /S7
Ft G,A5
Top Bottom
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 2 0
Ft
Top Bottom Ft
Top Bottom Ft
Material
Material Method
Concrete 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 Size Maul
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Forrnatipin Description
C 1
7s / %,' c4 i s79.ve
d / / 36 /Colic
R6 / gl0 S C1~;74C
12 REMARKS
LC
JAI' Z 3 2013
REUH\
NOV — e 201n
Pr w-pcsino Unit
DWQ/BOG
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 OW E
t1
SIGNATURE OF CERTIFIE • WE
C
iONS
N,TRACTOR DA
P066( �' 5
PRINTED NAME OF PERSON TRUCTING 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) 807-300
Form GW-la
Rev 11/08