381601_Well Construction - GW1_20100615

ELC
RESIDENTIAL WELL CONSTRUCTION` 4a2010
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 ,,
WELL CONSTRUCTION PERMIT# Lc../ o? 0119 zje)03 a2
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 31/
DATE DRILLED 9.,/,2iViet
TIME COMPLETED 3 00 AM Ef PM
4 WELL LOCATION.
CITY FA' f Il C t.J COUNTY 81)-A CO M 6
pitA/Adit ss (evt
(Street Name, Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOPAAPHIC / LAND SETTING (check appropnate box)
lope ❑ Valley ❑ Flat ❑ Ridge 0 Other
LATITUDE/0 36 !!S' ,3( SISSY r " DMS OR 3x XXXXXXXXX DD
LONGITUL 5 g%° " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Owner Name
foil & gait' /
Atreet Addre
iev.sse- /VG „a 88a
City or Town State Zip Code
(g;8) ;-"co
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH. bQ S /
b DOES WELL REPLACE EXISTING WELL? YES Z( NO ❑
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASINO 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) 5- METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount 4 %PA --
3 d FT
eJ
c� r; T Cur .
g. WATER ZONES (depth)
Top Bottom /0 Top Bottom
Top Bottom SOO ' Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 24' Ft GriS 24r/e rpotzd
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 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
0 / /y
1//2-9
2.N / 2q
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/
/
/
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12 REMARKS
Formation Descnpbon
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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
SIGNAT
/161/evel
ERTIFIEDie
CONTRACTOR DiATE
Ul . o s
PRIN ED NAME O F PERSON ONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mali Service Center - Raleigh, NC 27699-1617 Phone No. (919) SOT•6300
Form GW-la
Rev 11/08