383056_Well Construction - GW1_20100507

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Deparbnent 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
( 82E) 258-8496
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 20 ©S" t I f5'.
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(a applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [J'
DATE DRILLED9 -/0
TIME COMPLETED 3 IO
4. WELL LOCATION.
CITY 5-4.cn-14'0'7J4,14
4✓cka /494 I
AM O PMZ
COUNTY ,(Iw..e..•►!c
(Street Name Numbers, Community Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
[ Slope ❑ Valley O Flat 0 Ridge O Other
LATITUDE 36 ° 3 7 ' J /d " DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 ° 24/' 5-2q ' " DMS OR 7x XXXXXXXXX DD
Latdude/longitude source [ PS Qropographic map
(Iocabon of well must be shown on a USGS topo map andeltached to
this form if not using GPS)
8WE ER
Ot Qmp Teek
30 as Ya. i ; l 1 RoeLd
Street Address
City or Town
($2.3) eI5- 3i -c
Area code Phone number
NC 377�?
State Zip Code
6 WELL DETAILS
a TOTAL DEPTH' 60f
b DOES WELL REPLACE EXISTING WELL? YES O NO ❑
c WATER LEVEL Below Top of Casing "' ' 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) METHOD OF TESTB1owing-Rig
f. DISINFECTION' Type Chlorine Amount /' r a
Top
Top
Top
3 '=' 9 b
1. "J
g. WATER ZONES (depth)
Top 31 rr Bottom Top Bottom
Top 5 Z° Bottom Top Bottom
Top sr° Bottom Top Bottom
7. CASING Depth Diameter
Top 0 Bottom 2S' Ft 4,J2I"
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Material
.fd4/L/ /'c/ (
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
Bottom Ft
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom
ZS / 1s05"
/
/
12 REMARKS
Formation Descnption
(%y.
MAY ()7291C
Information Pmrac�,
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
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTIIUC
ELL
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. (919) 807"6300
FEB `' 2013
FormGW-la
Rev 11/08