388615_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: ff11 ��/y�
WELL CONSTRUCTION PERMITS WE I 2'6 ID"bcY374
OTHER ASSOCIATED PERMIT#(dappicable)
SITE WELL ID #(If applicable)
3 WELL USE (Check Applicable Box) Residenbal Water Supply «
DATE DRILLED JG' //D
TIME COMPLETED / S 4) AM 0 PM 3
4, WELL LOCATION: �
CITY AO to 3 Je " COUNTY .tSde^t-a t
f Ivtc,G / / 7` 12-8'
S•'m
(Street Name, Numbers, Community, Pielivision, Lot No , Parcel Zip Code)
TOP GRAPHIC / LAND SETTING (check appropnete box)
odope ❑Valley ❑ Flat ❑Ridge ❑Other
LATITUDE 36 ° 37 ' 35/Z ' " DMS OR 3x XXX 00(XXX DD
LONGITUDE 75 °4// _,.7S 7 " DMS OR 7x XYYYYYY)X DD
Latdude/longitude source [ S []topographic map
(/ocebon of coed must be shown on a USGS topo map andsfteched to
this form if not using GPS)
b. WE�071EIRI �^ '
'pr.Nre 64Ni 1 '311-1.
Stree Address
A—eae-1)/lCU N� AF816 _
City or Town State Zip Code
Area code Phone number
8. WELL DETAILS'
a. TOTAL DEPTH.
a 0 s'
b DOES WELL REPLACE EXISTING WELL? YES 0 NO DV
c WATER LEVEL Below Top of Casing FT
(Use "+" If Above Top of Casing)
d. TOP OF CASINO IS 1 FT Above Land Surface*
`Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) 10 METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount 'V o2.
•
•
g. WATER ZONES (depth)
Top Y ° Bottom Top Bottom
Top / 3 O Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 37 Ft d J' 32X1/
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
Top Bottom Ft to in
Top Bottom Ft in in
10 SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / SG
32 / ??
37 / _2 .>s"
12 REMARKS
Fo.mabon Description
City
4-. izt
PACE
r,0.0 — g ?nil
.rf�rr•,74i^n Processing Unit
DWQ/BOG
EL
90.11
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
OF CERTIFIED L C TRACTOR D • E
Ord, s
PRINTED IME OF PER CO STRUCTING THE WELL
Submit the original to the Div Ion of Water Quality within 30 days. Attn: Information Mgt°
1697 Mall Service Center — Raleigh, NC 27699-1617 Phone No. (919) 7-6300
Form GW-1a
Rev 11/08