384569_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma Deparbnent 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# (jf E j cp160 " lib 1(09
OTHER ASSOCIATED PERMIT#(A applicable)
SITE WELL ID #(A applicable)
324569
g. WATER ZONES (depth)
Top Bottom / 60 Top Bottom
Top Bottom / 8 `' Top Bottom
Top Bottom 3 (0 Top
7. CASING. Depth cr /Diameter
Top Bottom D Ft Sp r �S
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Tide
wing ?r
trial
CSI 12L/
Top Bottom Ft
Top Bottom Ft
Material
Method
9. SCREEN Depth Diameter Slot Size Material
3 WELL USE (Check Applicable Box) Residential Water Supply D Top Bottom Ft in in
DATE DRILLED S
TIME COMPLETED A`r((O
4. WELL LOCATION.
CITY l (fiC e j
AM ❑ PM Er.'
COUNTY / ,/!-1(d stf ,l,f
am8r),Ity er(vid/et,- �(J 3
(Street e, Numbers, Community, S bdivision, Lot No Parcel Z p Code)
TOPOGRAPHIC / LAND SETTING�(check appropnate box)
❑Slope ❑Valleys❑CFlat QRtage pother
LATITUDE 36 �.+ ° ea %3 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° Ya7 ' 3 ' / " DMS OR 7x xxxxxxxxx DD
LatitudeAongitude source PS OTopographic map
(location of well must be shown on a USGS topo map andatached to
this form if not using GPS)
5.4ttELL OWNS
r e J c p. es �
er N
tint_ LOO
treet Address
OtnCit
City or Town
10 3—
Area code Phone number
6 WELL DETAILS*
a TOTAL DEPTH'
HC ,2876I
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0
NO
c WATER LEVEL Below Top of Casing /9(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) 36 METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount 3De7
Top Bottom Ft. m 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
1'1
SS / 77
�l ins
/
/
/
/
/
/
12 REMARKS
Formation Description
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/-c)r/K
RECEIVE
JUN 15 2010
Information I'roa.,sstiig Ui,rt
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 THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
F C RTIFI ER1ACTOR -W..
CO
PRINTED`NAME OF P RSO KISTRUCTING 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]
t; l
Form GW-la
Rev 11/08