386227_Well Construction - GW1_20100812

RESIDENTIAL
WELL CONSTRUCTION RECORD/Y
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. p
WELL CONSTRUCTION PERMIT# (,if,l �D10 -v) 984
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(A applicable)
3 WELL USE (Check Applicale Box)
DATE DRILLED
TIME COMPLETED
Residential Water Supply
AM PMp'
4. WELL LOCATION.
CITY J rave"), COUNTY Aim rC9,i‘ be.
y-()t //lWQ//AU
(Street Name, Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOP RAPHIC / LAND SETTING (check appropnate box)
lope (Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 3s ' OZ/ / " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 %k° 27' 3/4/ / " DMS OR 7x XXXXXxx(Xe DD
LattudeAongttude source PS ❑topographic map
(locabon of sell must be shown on a USGS topo map andattac ted to
this lam !f not using GPS)
5. WE OWNER
h N /11 otz, o2�t
Owner Name
w; d E; (1d / lip-, L
S t Address
fc eruprai/le Mc. a87g7
City or Town
(763) 2B— 46, OD
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH.
b DOES WELL REPLACE EXISTING WELL? YES 0 NO (�
c WATER LEVEL Below Top of Casing (� 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) /0 METHOD OF TEST Blowinq-Rig
f. DISINFECTION Type Chlorine Amount
State
Zip Code
yp s
336227
g. WATER ZONES (depth)
Top Bottom a/ea Top Bottom D v Top Bottom v Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth 2 Diameter Weight Material
Top a Bottom l.3 Ft 6, 2.$- , f ( i icre/
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 pi Concrete Gravity -Flow
Top Bottom Ft
Top Bottom
Ft
Material Method
9. SCREEN. Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10. SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / /D
013 / YOS
/
/
/
/
12 REMARKS
Slot Size Material
in
in
m
Size Material
Fo rmabqn Descnption
Se( �5 'z
ell
GM4', 5�
D Q 1
DEC 2 I2
ECFR/ED
Ain 9 ?Ole
, netion Proces sin (nit
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
�a10SIG ATUR OF CERTIFIED W LL CONTRACTOR DAT
ii
PRINTED NAttE OF PERSO
NSTRUCTING 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. [phone]
Form GW-1 a
Rev 11/08