388607_Well Construction - GW1_20101108

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
( 8 2 a 258-8496
Area code Phone number
2 WELL INFORMATION: //� (
WELL CONSTRUCTION PERMIT# LLJ e I a 6 (0 ' GO39�
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(d applicable) /
3 WELL USE (Check Applicable Box) Residential Water Supply [2
DATE DRILLED 4 20 %©
TIME COMPLETED /0 ' 3iJ AM [7 PM ❑
4 WELL LOCATION.
CITY h✓l"-e• ✓`/te COUNTY
(Street Name Numbers, Community, Subdivision Lot No Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING (check appropnate box)
lope (Valley 0 Flat 0 Ridge ❑ Other
LATITUDE 36 " 4/7' 7s 6 ' " DMS OR 3x )00000 xxx DD
LONGITUDE 75 °J' r ? / " DMS OR 7x XXXXXXXXX DD
LatitudeAongitude source PS Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
3 L OWNER
CIA—(2E.6(46
Owner Name //
S Address
Z;stti, (e /1/C ?8 28 7
City or Town State Zip Code
c2212) 30— f-1i7
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH' 4/VC
b DOES WELL REPLACE EXISTING WELL? YES 0 NO.er
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) SJ METHOD OF TESTBl0W1ng-Rig
f DISINFECTION Type Chlorine Amount rg Z.
g. WATER ZONES (depth)
Top %(? Bottom Top Bottom
Top .1 i-i) Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top D Bottom f s Ft Ws' / '✓�
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 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
t� / Sv
/
�/ 44 4
/
/
/
/
/
12 REMARKS
Size Material
Formation Descnption
C%y
fled
. cr/f(
n�
Q\(l �fAcessr�9�
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
Ji<<.) It. La..jJ
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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]
Form GW-la
Rev 11/08