388617_Well Construction - GW1_20101108

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 (Indnndual) Name
Ferguson's Well and Pump,
Well Contractor Company Name
2731 New Leicester Hwy.
LLC
Street Address
Leicester,
NC 28748
City or Town State Zip Code
( 828 258-8496
Area Code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 2,910 - OC 4,4y
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(1f applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED JV --0 ' - "
TIME COMPLETED 3
AMP PM❑
4 WELL LOCATION.
`
CITY 44,01/!., COUNTY yes.,-,4.p.y 4 c.
0—c 50,i Cs.)-- .l0r l
(Street Name Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOP9GRAPHIC / LAND SETTING (check appropriate box)
❑,lope ❑ Valey ❑Flat ❑Ridge ❑Other
LATITUDE 36 ° 'yZ ' 01-7 " DMS OR 3X.)00000000( DD
LONGITUDE 75 ' 3Y 444 ' " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source PS Qropographic map
(iocabon of1.44.11 must be shown on a USGS tepo map andaitached to
this form if not using GPS)
WELL OWNER
(dc 1;nsa7\
Owner Jo �NaWh/'s ers'ni iJ/"tl-)r.
tAddress.
City or Town
&a8) (DO(0'9r7leS
Area code Phone number
/vc a8ta
State Zip Code
6 WELL DETAILS
a TOTAL DEPTH. 30
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing G D 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
3 METHOD OF TESTBlowing—Rig.
e. YIELD (gpm)
f. DISINFECTION. Type C h l o r i ne Amount 3 o L
3 1v t *.p 17
�
g. WATER ZONES (depth)
Top /1 61 Bottom Top Bottom
Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING. Depth Diameter Weight Material
Top 0 Bottom /v 2 Ft L./Z1' SD.rtJ i/,c-
Top 2 174-, Bottom
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
Top Bottom Ft in
Top Bottom Ft in
in
in
m
10. SAND/GRAVEL PACK'
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / c
_22_J
3Or
/02
/
/
/
/
12 REMARKS
Formation Description
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JAN ,& z013
VFD
Nay - 2010
nforrn5uo'_ornrpcsinfg IIRtt
r)WO/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
. ?-14;-- `/'i` �✓� ,;.. /I) .11-/0
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING 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. [phone]
Form GW-la
Rev 11/08