GW1-2021-03519_Well Construction - GW1_20210607

I
r~ ¢ RESLI ENML WELL CONSTRUCTION RECORD
North Carolina Departrna it a£Environment and Natural Resources-Division of Water Qtraiity
LL .—
WELL CONTRACTOR CERTIFICATION# �t, er
1.WELL CONTRACTOR: g. T ZONES(d
TONY R DAMS Top_,_ Bottom !w i Top Bottom
Well Contractor(Individual)Name : Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness]
1481 LARRY DAVIS ROAD 7. CASs G: Depth � , Dim aeter Weight Material
street.Address Top—T f Bottom—1 Ft 24 1.5 Cement;
LANALE NC 28090 Tap Bottom Ft
City or Town Stan Zip Code Top Bottom Ft
1 7041 276-3434
Area code Phone number B. GROUT: Depth Material Method
2.WELL INFORMATION: To U Bottom 14 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# f 14w Top Bottom Ft
OTHER ASSOCIATED PERMIT#(If applicable) Tap Bottom FL
SITE WELL ID#(tF applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check AppNcabie ox): Residential Water Supply CfO : Top Bottom Ft. In. in.
DATE DRILL : Top Bottom Ft. In. in.
TIME COMPLETED £ _ AM i] PMAOOO" Top Bottom FL in. in.
4.WELL LOC TION: 10.SANDIGRAVEL PACK:
ry4�, _ Depthfiize Material
CI M��mil _COUNTY Top, aattom t 78—M Gravel
L Top Bottattt FL'
( treat Name.Numbers,Community,S on.Lol No.,Partial,lip Code) Top Bottom Ft
TOPOGRAPHIC/LAND NG: (check appmprista box)
CSlope ❑Valley erat ORldge pother 11.DRILLING LOG
'Top Bottom Formation Description
LATruD _f DMS OR 3X. 5oc&=DD f
LONGITUDEIZZ XX
�MS OR 7X.XXXXXXXXX DD /
Latitudellongitude source: JDW Oropographic nap /
(location of well must be shown on a USGS topo moo andattachedto
this form if not using GPS) l _
nor Name /
j
�_ t
it'tl
s d treeeta ��s 1 In,� r
City or Town Stile Zip Code j
U j
Area code Phone number
12. REMARKS:
B.WELL .�
a. TOTALAL DEPTH: '
b. DOES WELL REPLACE EXISTING WELL? YE S❑ NO,6�
I DO HEREBY CERTIFY THATiTHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use`+•If Above Top of Casing STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL OWNER.
d. TOP CASING IS .Above Land Surfa
•Top ce"
of casing terrrsir+ated at/or below
land sur`ace may-require i !'
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE CIF WRTIFIED WELL NTRACTOR DATE
e. YIELD(gpm): METHOD 91F TEST 7--:� TONY R DAVIS
f. DISINFECTION:Type octrt� PRINTED NAME OF PERSONICONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality- information Processing, Form UM
1617 Mail Service Center,Raleigh,NC 27699.161,Phone:[phone] Rev.2/09