384563_Well Construction - GW1_20100615

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
( 824 258-8496
Area code Phone number
2 WELL INFORMATION.
State Zip Code
WELL CONSTRUCTION PERMIT# ciLs AO I c -6 0 a a-8
OTHER ASSOCIATED PERMIT#(A applicable)
SITE WELL ID #(ir applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 13
DATE DRILLED ' f -/0
TIME COMPLETED 1 " 30
4. WELL LOCATION
CITY ZelCes Jr-'
AM PMe!
COUNTY AAto►�t
(Street Name, Numbers, Community Subdmsion Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
p Slope oValley ❑Flat ❑ Ridge ❑ Other
LATITUDE 36 ° 36' ''7Z 7' "DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 %'3 ' )1 s" r " DMS OR 7x xxxxxxxxx DD
Labtude/longrtude source irtPS Qfopographic map
(location of well must be shown on a USGS topo map andaftached to
this form if not using GPS)
5. WELL OWNER
_ F S 4ce,2.4'",, -F7 Pf
7;Oymer Name
15(Q lt,th(18- MAt AdAddress
P` d KS MI tit/
ity or Town
S/Og%;8E'3
Area code Phone number
State Zip Code
6 WELL DETAILS.
a TOTAL DEPTH' ;6 r
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing VS0 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) %1) METHOD OF TESTB1OW1ng-Rig
f. DISINFECTION Type Chlorine Amount 1 vZ
33 4, 563
g. ,WATER ZONES (depth)
Top /470 Bottom Top Bottom
Top ,yO Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING Depth Diameter Weight Material
Top 0 Bottom 4/6 Ft e�%2i" .r r�d'�� ��`
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 Slot SIW �L 1 Ida �rla�
Top Bottom Ft in in �f
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK'
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 4.%/
/fj
/
/ JUN I 5 2010
Formation Descnption
(icy
RFcEIVE0
nformatD i WP g sing- ill
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
gr.u► dt 64I wt$
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