386226_Well Construction - GW1_20100812

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:
WELL CONSTRUCTION PERMIT# 12 S E L P61 U- Goa 88
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(I/ applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply !7�
DATE DRILLED /l%4D
TIME COMPLETED (7' 30 AM PM ❑
4. WELL LOCATION.
CITY P//)ii//fu l COUNTY AJAC9M
5..4-D N.14(5
(Street Name umbers, Commun Subdivision, Lot No Parcel, Zip Code)
TOP HIC / LAND SETTING (check appropriate box)
❑ VaNey ❑ Flat ❑Ridge ❑Other
LATITUDE 36 E.3'.t1 1 ' K 5 r - DMS OR 3X XXXXXX 00( DD
LONGITUDE 75 8L ° 20 XX " DMS OR 7x )XXXXXX DD
Latitude/longitude source S Dropographic map
aocaborr of well must be shown on a USGS lopo map andattedred to
this form Knot using GPS)
S. x.rowNER n n
V-4 L � i 6 ftp,H C) .0 ref
Owner Name
AD pp) >i;"/ r
t Address
y-i(U�e�
City or Town
(%2W) n99
Area code Phone number
6 WELL DETAILS*
a. TOTAL DEPTH*
NC_ a g73
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ia' NO ❑
c WATER LEVEL Below Top of Casing 50 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 variance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) oR METHOD OF TEST Blowing—Ri g
f. DISINFECTION. Type Chlorine Amount /150�-
g. WATER ZONES (depth)
Top Bottom /
Top Bottom 2.4
Top Bottom
7 CASING Depth
Top !i Bottom ( $ Ft
Top Bottom Ft
Top Bottom Ft
3'36226
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
r, �s ?1(�, /2Y Orcfj) 2z
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete
Top Bottom Ft
Top Bottom Ft
Method
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. SANDIGRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
t? / irk
—40LI '
' LC
Size
Material
Formation Description
%,
loa(s7�rtic
t lS
— +AN ®Z013 PI V 16.0
/
/
12 REMARKS
AUG 1 2 201u
Infnrrnat,erir3092!gq
DW0/Sflc
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
PROVIDgD TO THE WELL OWN
SIGNATU E OF CER IT FIEd
L CONTRACTOR D' ATE
i/ edf
PRINTED NME OF PERSON CONSTRUCTING 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