GW1-2021-06418_Well Construction - GW1_20210915

# _ RRIDENTW WELL CONSTRUCTION RE�ORD
�• f CC I
North Carolina Department of Environment and Natural Resources-Division of Water Quality
"�- WELL CONTRACTOR CERTIFICATION
1.WELL CONTRACTOR: g. WATER ZONES(d jth):
TONY R DAVIS Top If Bottorr'im Top Bottom
Well Contractor(Individual)Name Top Botlom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAMS ROAD T. CASING: Depth Diameter Weight Material
Street Address Tap_Bottom >t. 24 1.5 Cement
LAWNDALE NG 28090 Top Bottom FL —
City or Town State Zip Code :
704 t 276-3434 _ Top Bottom I t.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top O Bottom 20 Ft, Concrete Truck
WELL CONSTRUCTION PERMIT# Top Bottom Ft. -
OTHER ASSOCIATED PERMIT#(if app)icable) Top Bottom Ft
SITE WELL ID#Crs apprsabis} 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Ch pplicable Box): Residential lrlaterSuppiy Top Bottom Ft. in. in.
DATE DRILLEDeck l Top Bottom Ft ln. in.
Top Bottom Ft. in. in.
TIME COMPLETED �, AM❑ PM Z.r•'
4.WELL LOCATION: 10,SANDIGRAVEL PACK:
Depth iz se Material
CITY: TY_ Top -Bottom=,e Ft. 78—M Gravel.
, Top Bottom Ft
(Sweet Name,Numbers, munity,Su on,Lot N . P Tap Code} Top Bottom Pt.
TOPOGRAPHIC i LAND ING: (check appmpriva box)
USlope DValley at DRidge ❑Other 1f. DR1LLINGLOG
�}� 'Top Bottom Formation Description
LATITUDE ;,, 5 i��t DMS OR kX.X)cX�tXXXXX Do /
LONGrFUDE�.-&9L �DMS OR I X.VaVJ =DD /
Latitude/longitude source: 4901 Oropographic i nap
(location ofwetl must be shown on a USGS topo ma,)andattachedto
this form if not using GPS)
S.WELL QINNER
Vt M V�co9Af 5 0AJ J
J
Ow er Name
Street Address
City or Town Stan: Zip Code J _,�• 1;� ;.E"" a^t`•
Area code Phone number
: 12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O N04-+' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N
c. WATER LEVEL Below Top of Casing:_� FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'ifAbove op of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED 0 THE WELL OWNER.
d. TOP OF CASING IS Fr.Above L and Surface' i ��"'� � ;= f'Top of casing terminated atfor below land surfai a may,require i
a variance in accordance with ibA NCAC 20.0118. S► NATU F CERTIFIED WE)�;CONTRACTOR DATE
a. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type Wo Amount PRINTED NAME.OF PERSON CONSTRUCTING THE WELL
E
Submit within 30 days of completion to: Division of Water Quality- Infonnatlon Processing, Form GW 1a
1617 Mail Service Center,Raleigh,NC 27699.16'i,Phone:[phone] Rev.2JD8
i