384564_Well Construction - GW1_20100615

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 W / /l
WELL CONSTRUCTION PERMIT# E I �') / 6-6 O I OCR
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ii amicable) /
3 WELL USE (Check Applicable Box) Residential Water Supply [�
DATE DRILLED
TIME COMPLETED AM Q PM ❑
4. WELL LOCATION. CITY 1 t( G51 -t.r'
?We- br
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPH HAND SETTING (check appropnate box)
0 Slope alley 0 Flat 0 Ridge 0 Other
LATITUDE 36 35* 3 g•' 5f 7 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 X" 3 f' ? / oi" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS Dfopographic map
(location of well must be shown on a USGS topo map andattached to
this fain, if not using GPS)
L L OWNER /n
hi ES 24-Vr) /(e
i....er Name
5 ...Cm-Jo/fey ark lltuef
Street Address
COUNTY �V/l( 47'1 6(_
Pill UP
City or Town State Zip Code
C�-
Area code Phone number
Svc aa'8e�
6 WELL DETAILS'
a TOTAL DEPTH' /7S /
b DOES WELL REPLACE EXISTING WELL? YES 0 NO gr''‘
c WATER LEVEL Below Top of Casing % 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 m accordance with 15A NCAC 2C 0118
e. YIELD(gpm) JV METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount If 0 2
3(L; 4. 561
g. WATER ZONES (depth)
Top Bottom MO Top Bottom
Top Bottom / o Top Bottom
Top Bottom � T\ti7 Bottom
367 Thickness/
7 CASING: Depth .. ` . Weight Material
Top D Bottom 53 Lo, /-T ,LC5/)&2/
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top Bottom Ft
Top Bottom Ft
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
�i/ 3D
all / 4/
'y1 / .S3
/
/
/
/
/
12 REMARKS
Slot Size Material
in
in
in
Size Material
Formation Descnption
c /a
S Sand I
Roc/c,
(3-Ar'V 7 .
\IFD
5 ?OM
Infurtnation Processinq Unit
DWt.trtiOG
1 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
SIGNATUR 0CERTIFIED
6//3(i/0
LL CONTRACTOR `` DAT
AdDIOEy W t /,7L7L
PRINTED NAM OF PERSON CSTRUCTING 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"6300
Form GW-la
Rev 11/08