388613_Well Construction - GW1_20101108

City or Town
4012) a99-y'e3az
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH. SOS
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028-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: �f
WELL CONSTRUCTION PERMIT# itfr/ ‘340I0-665575
OTHER ASSOCIATED PERMIT#(rt applicable)
SITE WELL ID #(ir applicable)
3. WELL USE (Check Applicable Box)
DATE DRILLED
TIME COMPLETED
4. WELL LOCATION.`
CITY f u r`t U/'(t✓ COUNTY &ACOM A.
Residenbal Water Supply
AM O PM[[?)
ki'S eLf CW fs 4$
(Street Name Webber*, Community Subdivision, Lot No Parcel Zip Code)
TOPO HIC / LAND SETTING (check appropnate box)
❑Valley ❑ Flat O RMge ❑ Olher
LATITUDE 36 3J % L y( " DMS OR 3X.X00000tXXX DD
LONGITUDE 75$Z- ° t/J-. Y / " DMS OR 7x XXxxYYYXX DD
Latrtude/longitude source L33r6- [Topographic map
(lbcabon of well must be shown on a USGS topo map andsttached to
this form Unot using GPS)
8.( i/ 436 d
Owner Name
/f( t9t5nN DE.
Stoat dress //
dith. u e C. g0.3
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO l�J
c WATER LEVEL Below Top of Casing SO 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) b METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount 2.102.
WATER ZONES (depth)
3 8613
Top Bottom 3/n Top Bottom
Top Bottom y20 Top Bottom
Top Bottom Top Bottom
Thlcknasa/
7 CASING: Depth Diameter Weight Material
Top (, Bottom Ft lroc zib, 5 //c Sj 2 /
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Ft Concrete Gravity -Flow
Top 0 Bottom 20
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft m in
Top Bottom Ft in in
10. SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Size
Llabartal
11 DRILLING LOG
Top Bottom Formabon Description
0 / 2-0 day
2fJ l 17 Skyetaki9x,c.
ger�
37 / Y
(71).l SOS
/
/
/
/
12 REMARKS
CL)
NO" — S 2n111
Infnrmation Processing Uni£
9 { awa/BOG
IAt' 9 ( 2f1t1
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 TD THE WELL OWN - R
SIG
TU
E 01= CEti'TIFIE C 0R DA E
DWELL CONTRA T
PRINT ED NAME OF 4SIO&ONSTRUCTING THE WELL
Submk the original to the Division of Water Quality within 30 days. Attn: InfomtatIon Mgt,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919) 807-300
Form GW-la
Rev 11/08