383054_Well Construction - GW1_20100507

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma 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
( 82a 258-8496
Area code Phone number
2 WELL INFORMATION %
WELL CONSTRUCTION PERMIT* I.CJfF/ o?d ill— 6611 d
OTHER ASSOCIATED PERMIT#(A applicable)
SITE WELL ID #(K applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [
DATE DRILLED el" v -'O
TIME COMPLETED 9 =12t) AM 342M ❑
4. WELL LOCATION -
CITY /i.el)11'
COUNTY P'4 s
ea-
441-5,(
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOP GRAPHIC / LAND SETTING (check appropnate box)
lope ❑ Valley ❑ Flat ❑ Ridge 0 Other
LATITUDE 36 °Ty ' a'7/ " DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 ° )7 ' 73y "DMS OR 7x XXXXXXXXX DD
Labtude/longitude source (3 4 Eiropographic map
(location of well must be shown on a USGS topo map andatteched to
this form Ifnot using GPS)
5 WELL OWNER
6afn u 4/-)de rs
Owner Name
treat Address
hecl� /V
s c. aSla .
City or Town State Zip Code
GUI) r713— 9765
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH.
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL. Below Top of Casing 1) 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) 'f 0 METHOD OFTESTBlowl ng-Ric'
f. DISINFECTION* Type Chlorine amount f/a z
g. WATER ZONES (depth)
Top ""� Bottom Top Bottom
Top''‘"1.-Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING Depth Diameter Weight Material
Top 0 Bottom 7j Ft 4/z� S,4eu
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 Ft
Top Bottom Ft
Top Bottom Ft
Material Method
Concrete 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
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
0 / (o r
71
Ft
Ft
Ft
Size Material
Formation Description
C�s4s
)
MAY wt, r L ,r,'s3
C v IV
/ lnforrrcto^
/ r wvnlRr )r
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
/
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
F/'l%C1 4412.e.
.r
PRINTED NAME OF PERSON CONSTRUCTING T1 J .
Submit the original to the Division of Water Quality within 30 days. 'Attn: Information Mgt, p17�lrv_1a
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] FEB rev 11/08
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