388611_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 PERMITS W Fi D901 U"60 t Ci2
OTHER ASSOCIATED PERMIT/kit applicable)
SITE WELL ID*Of amicable)
Residential Water Supply Er -
AM ❑ PMEJV
COUNTY 1OACOMhe_
C. 1m'sS /1
(Street Name Numbers! mmunity, Subdivision, Lot No Parcel, Zip Code)
TOP a = ' • HIC / LAND SETTING (check appropriate box)
r lope D Valley ❑Flat ❑Ridge D Other
LATITUDE 36 3S " 35 ' 7 v f " DMS OR 3X. XXXXXXXXX DD
LONGITUDE 75 j /�/_XX
" DMS OR 7x )00000 X DD
Latltude/Iongitude source PS Qropographic map
(ocabon of eel must be shown on a USGS topo map andatteched to
this form if not using GPS)
3 WELL USE (Check Applicable Box)
DATE DRILLED ' Q
TIME COMPLETED
4. WELL LOCATION:
CITY eu, fie
OWNER
Owner Name
ry-„r„Jo
t Address
ell; tiro
City or Town
(82)?) a55— / 9 Y
Area code Phone number
State Zlp Code
g. WATER ZONES (depth)
Top Bottom no
Top Bottom S()
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
3 yt fi11
7 CASING: Depth Diameter Weight /� Material
ho
Top 0 Bottom 70 Ft ,A5 U6i/ok' �I/c5 L/
Top Bottom
Top Bottom
Ft
Ft
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in kn
Top Bottom Ft in in
Top
• Top
Top
8 WELL DETAILS'
a TOTAL DEPTH. 5
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing ui 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). `S METHOD OF TEST B1owinq—Rig
f. DISINFECTION. Type Chlorine Amount Z+'09�
10 SAND/GRAVEL PACK.
Depth
Bottom Ft
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom
n� / SD
Size Material
Formabpn Descnption
y
__,20_/ (r,S S edtif7en A/f
. 6 S / 77D /dgc<
?D !3oS
ELC
2 6 ?m3
/
/
12 REMARKS
RECEIVED
NUV - 8 LULU
Information 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 T RECORD HAS BEEN
PROVIDED TO THE WELL OWN
SIGNATURE CE TIFI LL CONTRACTOR
PRIN ED NA E(OF PERSON C TRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,
1617 Mali Service Center - Raleigh, NC 27699-1617 Phone No. [phone]
Form GW-la
Rev 11/08