384560_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 State Zip Code
( 824 258-8496
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# JOO 0Q s?
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID Cif applicable)
3 WELL USE (Check
Applicable Box) Residential Water Supply
DATE DRILLED J' -2'; -, o
TIME COMPLETED 9'; f D AM [(PM ❑
4. WELL LOCATION.
CITY r�} 04,
11-1S ++ Jrr) lv,. t
COUNTY /1 •24a.-1,�C
(Street Name, Numbers, Community Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
ope ❑Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 ° `1' 37 f " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ' Z c XXXXX ' " DMS OR 7X XXXXDD
Latitude/longitude source [�i S Qropographic map
(locabon of well must be shown on a USGS topo map andattached to
this form If not using GPS)
L OWNER t�
Gt� i'hS art, (t ! /dfs
Owner Name
/07 /LJ/) isloer,'n ? T�I I, f' ( 17�'.i ve_
Street Address
lvc Z2d�
City or Town State Zip Code
Loo(..P' 9 i a8
Area code Phone number
6 WELL DETAILS ��
a TOTAL DEPTH.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (
c WATER LEVEL Below Top of Casing 4/0 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) ,T METHOD OF TESTBI Owi ng-Ri g'
f. DISINFECTION Type Chlorine Amount .2 Z •
'-) 4 n C
t 0 s
g. WATER ZONES (depth)
Top /4, Bottom Top Bottom
Top 3/Sr Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth
Top 0 Bottom 1(-)
Top Bottom
Top Bottom
Diameter
Ft /h-
Ft
Ft
Thickness/
Weight Material
r 'e
8 GROUT Depth Material 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
Slot Size Material
in
in in K
10 SAND/GRAVEL PACK
Depth Size Material
Top
Top
Top
Bottom Ft
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
0 / 7s- CAI
Jr / 1-0 S4rif
o / 4/2 s' r�r�,• K
/ REC
/ JUIv >!
/ � 2010
Infor iatUWp sing Unit
/
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
MUCyf
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