384566_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma Department of Environment andNatural 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# W L S ao 10- 00 3 9 8
OTHER ASSOCIATED PERMIT#(ir applicable)
SITE WELL ID #(it applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Er. --
DATE DRILLED <S,/lD
TIME COMPLETED /0, ?)) AM PM ❑
4. WELL LOCATION
CITY A e v,i / COUNTY A rtC19M be
S►�n 1 } I�1 1FNaad
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPS_GRAPHIC / LAND SETTING (check appropnate box)
lope ❑Valley ❑Flat D Ridge ❑Other
LATITUDE 36 3p° 30' 3 yt ' " DMS OR 3X xxxxxxxxx DD
LONGITUDE 75 $Z ° "DMS OR 7x XXXXXXXXX DD
LatitudeAongitude source PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this fomr if not using GPS)
5. WELL OWNER
r'rv�c /VieelI lorr e.s Arnert ca,-
Fishexl lie
15 Smoke 1Pcor k. I-V�1\w
Street Address .1
Owner Name
t shev;lle,
City or Town
(gab) a3a-(0019
Area code Phone number
N C a%804)
State Zip Code
6 WELL DETAILS' ,
a TOTAL DEPTH. 3'S /
b DOES WELL REPLACE EXISTING WELL? YES 0 NO r
c WATER LEVEL Below Top of Casing ZO 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) S METHOD OF TEST Blowing —Rig
f. DISINFECTION Type Chlorine Amount 2Yoz
3346
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness(
7 CASING. Depth Diameter Weight Material , ,\‘'.")
Top Bottom Ft 1 % t
Top Bottom Ft w y tir
Top Bottom Ft " - F a
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete Gravity —Flow
Top Bottom Ft
Top Bottom Ft
Method
9 SCREEN: Depth Diameter Slot Slze Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK.
Depth Slze Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formabo Descnpbon
O / 70 c Pay
70 / 937 'ego 4157n, e.
4n, / tat /1-4C
10 2..1 `7<G
/
/
/
/
/
RECEIVED
JUN E2010-
/ Inf.,rmatton Proc''ginO 1)nit
/ nWOFBOG
12 REMARKS
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 N E OF gitTIFIEDLL C NTRACT
r
STR
PRINTED NAME
R
DA E
PERSON C UCTING 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-la
Rev 11/08