384573_Well Construction - GW1_20100615

StAddress
1r t N�S U l Iir_
City or own
(Z R) 5a-55I
Area code hone number
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
( 828 258-8496
State Zip Code
Area code Phone number
2 WELL INFORMATION: ( 1
WELL CONSTRUCTION PERMIT# LU e 1 Ao o -ooa 3 q
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(rf applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 13
DATE DRILLED " /F`''
TIME COMPLETED / • .3`2 AM 12/PM ❑
4. WELL LOCATION
CITY Ic.re t i+.'
.0'%y t
COUNTY Ai (Q.,'
(S(roet Name Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Slope ❑ Valley ❑ Flat 0 Ridge ❑Other
LATITUDE 36 ° 3i ' 6Jt " DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 ° 4S , 80"i " DNS OR 7x XXXXXXXXX DD
Latitude/longitude source [S oropographic map
(locabon of sell must be shown on a USGS topo map andatlached to
this form If not using GPS)
5. WELL OWNER AAE S. COn.54pc, GAfjJ
Owner Name
72,1
NC , W78(
State Zip Code
6 WELL DETAILS 3�r
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0 NO I(
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) Y METHOD OF TESTB 1 o W 1 n g— R 1 g'
f. DISINFECTION* Type Chlor ine Amount 0
3Loci A
g. WATER ZONES (depth)
Top /Z" Bottom Top Bottom
Top 3 /g Bottom Top Bottom
Top Bottom Top Bottom �f
Thickness/ 1t 701 "
7 CASING* Depth Diameter Weight 3UMaterial„ f, i
Top 0 Bottom ,i-o Ft 611r— ail/ 4 MIS
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Material
Method
Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft
Top Bottom Ft in in
in in
10 SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
vr-
Size Material
Formation Descnption
s-.) / 35/1-
/
RECE '
=1.)
12 REMARKS
jut:" 1 5. 701U
Infaift8tior Processoy unr
DW QIBOG
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
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