386222_Well Construction - GW1_20100812

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envrronment`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
( 828) 258-8496
Area code Phone number
2 WELL INFORMATION
State Zip Code
WELL CONSTRUCTION PERMIT# W El 06I6,-'0 013 D
OTHER ASSOCIATED PERMIT#(A applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply p'''.
DATE DRILLED %/ !2a
TIME COMPLETED / rr 30 AM 0 PM (a
4. WELL LOCATION.
CITY Cjord /U^ COUNTY/A/A(0m /e
�1itrJVVRe- tirP` P?
(Street Name Numbers, Commurlity, Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Valley ❑Flat ❑Ridge OOther
LATITUDE 36.�s" 3S • 2✓f r " DMS OR 3X X)tXXXXXXX DD
LONGITUDE 75 $ 2. ��Z r " DMS OR 7x XXXXXXXXX DD
Labtude/tongitude source S Qropographic map
(locabon of well must be shown on a USGS topo map andattached to
this form if not using GPS)
(ELL
Owner Name IC-airwca.115
q� i"a y PO ad_
treet Address
Pc4en
City or Town
1 ckrexs LLC
Area code Phone number
kC.
State Zip Code
6 WELL DETAILS
a TOTAL DEPTH. p1 YS
b DOES WELL REPLACE EXISTING WELL? YES 0 NO Cf
c WATER LEVEL Below Top of Casing 2 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING 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 (0 y
V6222
g. WATER ZONES (depth)
Top Bottom /b 7 Top Bottom
Top Bottom / q0 Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top ) Bottom /Ay Ft /s,7A5 7/6,/,Zr 06C- a ?.J
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20
Ft
Top Bottom Ft
Top Bottom Ft
Material Method
Concrete 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. SAND/GRAVEL PACK'
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
90
So I //9
//9 / /z v
ixy / ztS
m ZU13
/
12 REMARKS
Formation Descnption
('ray
erds*
[/<-
MIR 11 9, 9010
rntormaton Proamrnn rand
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
SI
F C RTIFI
rki"1:/J! ,
PRINTED NAME OF PERSON TRUCTING THE WELL
Z
/0
D WE CONTRACTOR D E
S
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. [phone]
Form GW-la
Rev 11/08