388612_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: ' r
WELL CONSTRUCTION PERMIT# W e I A010 - O( O5(
OTHER ASSOCIATED PERMIT#(rr applicable)
SITE WELL ID t(ir appisable)
3. WELL USE (Check Applicable Box) Residential Water Supply E
DATE DRILLED /O' `/ -
TIME COMPLETED '1 ' 3 AM ❑ PM
4. WELL LOCATION:
CITY /3411%//e
COUNTY Xl • (004 iC
�(ltn Oita Pe x.✓L
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TO�P RAPHIC / LAND SETTING (check appropnate box)
[3'sk pe ❑ Valley ❑Flat D Ridge DOther
LONGITUDE 75 jJ "DMS OR 7X3X.XXX)OXXXXXXXXX DDDD
Labtude/longttude source E$ S :Topographic map
(bonbon of iael must be shown on a USGS topo map andaltached to
this tom? If not using GPS)
5. WELL • ER
Owner Name /
1 74 Ca rtt t1 Le bird
/4dre Street ss
61 N( ,Z1�
City or Town State Zip ode
Area code 'None number
6 WELL DETAILS' /
a TOTAL DEPTH. 712
b DOES WELL REPLACE EXISTING WELL? YES 0 NO C�
c WATER LEVEL Below Top of Casing 6'0 FT
(Use "+" If Above Top of Casing)
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) " METHOD OF TEST Blowing -Rig
f, DISINFECTION. Type Chlorine Amount /Z Ot,
3 S 6 2
g. WATER ZONES (depth)
Top .140 Bottom Top Bottom
Top rT' Bottom Top Bottom
Top G t42 Bottom Top Bottom
Thickness/
7 CASING. Depth Diameter Weight Material
Top 0 Bottom /ZO Ft AD,eer
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
Top Bottom
Top Bottom
Top Bottom
Diameter
Ft in
Ft. in
Ft in
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11. DRILLING LOG
Top Bottom
D / /is—
//r/ /20
/e0 / 7os'
/
/
/
/
12 REMARKS
Size
Method
Gravity -Flow
Slot Site Material
in
in
In
Material
Formation Description
C/w
s4//
6--ar•i(P
I„I,i n, gt19'
NEC
Nov - g ?�1n
'nfcrrvtinn Processing 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 OWN
SIG OF�R*IRIE ITRACTOR
P INTED N ME OF PER r N O' 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. (919) 9074300
Form GW-la
Rev 11/08