380378_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 31 4 0 -A
1. WELL CONTRACTOR:
Brian K. Wines
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
( 824 258-8496
Area code Phone number
2 WELL INFORMATION' r / c
WELL CONSTRUCTION PERMIT# Lk [-5 •Q4/5 - 633 2.1
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable) /
3 WELL USE (Check Applicable Box) Residential Water Supply Q"
DATE DRILLED f/ 1s Oir
TIME COMPLETED Al AM ( PM ❑
4 WELL LOCATION.
CITY /4s•.- L•`C+f
COUNTY , i-'."44.
Ald ie C, eek /
(Street Name Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope [Valley ❑ Fiat D1ge DOther
LATITUDE 36 " 3/ 700 "DMS OR 3x XXXXX)tXXX DD
LONGITUDE 75 " 23 ' ?I`/ " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source E PS propographic map
(location of well must be shown on a USGS topo map andattached to
this fomi if not using GPS)
5 LL OWNER 13n ,
Owner Na
144 B ape G II'w Lai .
Street Address.
-s heir, �L Z14.5
City or Town State Zip Code
(118) ;'0- V6t/
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH. )' s-
b DOES WELL REPLACE EXISTING WELL? YES 0 NO CJ
c WATER LEVEL Below Top of Casing 41 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) V METHOD OF TESTBlowi rig—Ri g
f DISINFECTION* Type Chlorine Amount Jc C Z
330,t378
g. WATER ZONES (depth)
Top Z7-' Bottom Top Bottom
Top Iry Bottom Top Bottom
Top VS' Bottom Top Bottom
Thickness/
7. CASING. Depth Diameter Weight Material
Top 0 Bottom -7/ Ft 6./Zr 5:f.tCL1 1-71-"C
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete
Top Bottom Ft
Top Bottom Ft
Method
Gravity -Flow
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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size Material
Formation Descnption
b / C4
cc / y/ Slcf/
7/ l s-di`
/
/
/
,-5 q
IAAN.11g2010
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12 REMARKS
DWC)/Ft(-)rz
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
/4 - o
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
(�
ire.", lam. 14,A•es
PRINTED NAME OF PERSO . r,i SCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mtn 5 2013
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] tl�
Form GW-la
Rev 11/08