GW1-2021-03252_Well Construction - GW1_20210628

. ESZX}EN'TUL WELL CONSTRUCTION RECaRg
and Resources-Division of WBte teal
r North Carolina Deper�t°nt of Environment Natural f� I � Q ty
WELL CO NTRAM aR CERTYFICATION#—2� (—8
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS TO Bottom, Top_]�»____Bottom
Weft Contractor(individual)Name Top Bottom Top Bottom________
DAVIS WELL BORING Tap Bottom TopL Bottom
Welt Contractor Company Name
Thicknestrt
1481 LAUY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Toli L_Bottom.40 Ft 24 j 1.5 Cement
LA DALE __ NC 28090
Top. Bottum Ft.,w �
City or Town State Zip Code Top Sottonl_-_-___Ft.
704a 276-3434
Area code Phone number 8. GROUT; Depth Material Method
2.WELL 10ORMATION:��.._,_ Top 0 Sotom 10 Ft. Concrete Truck
...._ _.
WEl,L CONSTRUCTION PERMIT# , Top Bottom Ft.
OTHER ASSOCIATED PERMTr#(if dppi6si ) loR Bottom Ft.
SITE WELL 10"applicable)
9. SCREEN:''Depth' . Diameter Slot Size material
3.WELL USE(Check Applicable Box): Residential Vtater SupplYP3/ Top Bottom Ft.�: In in.
DATE DRILLE A. r Top T,_Bottom Ft.� . In. in.
1 Top`' ' 9,ottom Ft.. tn:+ In.
TIME COMPLY i'ED AM O PM Q w wo
4.WELL LOCATION:` 10 SAND/GRAVEL PACK
Depth Blze Material
CITY y i ' urvnr T , m Ft 78 M Gravel
• f� /�.�' ,.�1.�.,!._j w j Top � Bottom, � �Fti r,
(Street Name,'Numbeis Community Subdivision,Lot No-Pai Code) Top Bottom Ft
TOPOGRAPHIC1LAND'SETTING: (chack appmpdats bo4
° 11 0 slope ovalley aWfgf—ciJ a cother i
DRILLING LOG
(� {�.� , �+/� yyyWyy ' ',Top Bottoot - Formation Description
LATI.I UDE "' ,--,���i DMS OR 4�X:XXXXX)ODIX DO
LONGtTUDE,X'ti'► f MS OR 7'X.XXXXXXXXX DO ! W
LataudeiJongttude,source: £ prbpographic•map•
(location of well must be shown on a USGS topo map andaffaohed to
this ibrrn If not using SPS) ! I !
5.WELL OWNER
Owner Name ,
Sb�aet Address
Citty or Town Ste.te Zip Code f
Area code ;phone number
B:WELL,DETAILS: 12. REMARKS;
a. TOTAL DEPTH:
b "DOES WELL REPLACE EXISTING WELL? YES 0 ""Nt, �
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Caring. ACCORDANCE WrrH"15A NCA'C 20,Wf`LL CONS'1'RtJCTiON:,
(Use'+•if Above Top of Casing)q� r"�' STANDARDS,AND THAT A COP1`.OF THIS HRECOFtD.HAS BEEN. 4 y
0,K00bED T4 THE WILL,OWNER.
d. TOP DF CASING IS_ � d$ FT'.Above Land Surface• ,
*Top of casing terrnina tz below land slur ace may require
a variance in accordance wM 15A NCAC 2C.0118:-.°-• St NATURE O CERTI IED WELL CONTRACTOR DATE
e. YIELD(gpm): ,, mA Ii OF TE81 TONY R'DAVIS
r. DISINFECTION: AmountPRINTED NAME OF PERSON GONSTRUCTtNG THE WELL.
Submit within 30 days of completion to: Division of Water Quality- inforntatlon Procesr9ing, I=pim GW 1a
1617 Mail Service Center,.R;alefgh,Nt 2709-161,Phone i­[phone]s ReV 2