383058_Well Construction - GW1_20100507

City or Town
c►) toA(4- S4as,
Area code Phone number
6 WELL DETAILS' �/
a TOTAL DEPTH. 7 V.r
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
( 82a 258-8496
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT* < 0/ 0 " 00 /2f
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable) /
3 WELL USE (Check Applicable Box) Residential Water Supply pV
DATE DRILLED "7//' "i2‘ - /z2
TIME COMPLETED %/ .' 4'° AM p PM ❑
4. WELL
//LOCATION.
CITY �!•c�� �C -
f✓°�V. %� f�. et /Cc:
COUNTY ,"evo, jc
(Street Name Numbers, Community, Subdivision Lot No
Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley ❑Flat E idge ❑Other
LATITUDE 36 ° 3 2 ' a'L r ' " DMS OR 3X XxxxxxxX (DD
LONGITUDE 75 ° <%b1' 22 7 " DMS OR 7X XXXXXXXXX DD
Labtudefongitude source [PS E3ropographic map
(location of web must be shown on a USGS topo map andattached to
this form if not using GPS)
5 LLR
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owner f ame
LLS 76 1-1-w9
Street Address
cl.�nnGnoa. IVC aR77R
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ 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) o 0 METHOD OF TESTB 1 O W 1 n g- R 1 g
f. DISINFECTION' Typo Chlorine Amount
g. WATER ZONES (depth)
Top 11 J Bottom Top Bottom
Top 17/15.- Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING. Depth Diameter Weight Material
Top Bottom -7-6 Ft 4./1 r
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top Bottom Ft
Top Bottom Ft
9. SCREEN- Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10. SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Slot Size Material
In
in
in
Size Material
11 DRILLING LOG
Top Bottom Formation Descnpbon
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12 REMARKS
,i nurmation Processrnn 1 !nit
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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
11.16- /U
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
lit 7t J
PRINTED NAME OF PERSON CONSTRUCTINf
LL
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]
FEB 2 5 9OR?V GW81a