HomeMy WebLinkAboutGW1-2021-07660_Well Construction - GW1_20211215 FROM FAX NO. May. 30 2012 05:51PM P2
'K'rf��n 1��• .�E SII)EN'TXAL w CUNSTI2tiCTIo!1tECf3Rb
ti � A'oYli Carolia:Depar!Mert Of Environment and Natural resources-Division of Water Quality
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WELL C=ONTRACTOIR CER271CATION#
I.WELL CONTRACTOR:
1"`ONY R DAVIS s., 7 ZONES(dopth•
Weli CorttraGtor(ladividuen Name -�----� T°�BOttom� Top Sol
DAVIS WELT, BORING Top__. �Sottnm
t"MID Contral Comparry Name Top—Sall- � Tflp��Sntfom
1481 TARRY rAVxS Tirl Tlticknes,J
SireelA drama 7. CA IH¢; Depth � bfameEct Walgttt Mati l
L4w•b�ALE NC 28090 Top Battorn..�i3Ft_ 24� 1.5 Cement
:ity or Town State Zip Code T°p . m Botto -t,_ _ ^
70_4i 276-3434 1'°P`...�Bottom Ft- ---
A'rea code P?wne number —
2 WELL INF0FtMATION: 9• GROUT; Depth Matarial
/RJC Method
ST , � f T0A 0 sottom 20 FL COncret:e Truck
WELL CONSTRUCTION TION PERMd�-
TCp 8cbom Ft.
07HERASSOCtATECFERN!T,,lappliz:is}
SIT$WELLis0,:iapprx rle +°A Bottom
3.WE 9, SCREEN; Depot Diameter mot Size ,
II USE(Check Applicab a Box}: Rasid�s► I i1Vater Suppf}�'� ; Top Rogo Ma nn
hA?EflFiiLL<:'J a !/ m~--•--F` �-
" Top _i30tbm Ft•��in. In.
TINE COAr,PLc'TE7 AM I .,
Top BotDam�^Ft in. — In-
4•WELL CATIQN; it).SAND/GRAVEL PACK
COUNTY aapth 8fze MatmFiat
/pToa _B°fia7^ t 7 Gravel
(S - he,N ors•:crrmurdn;S tvislnn,Lot -.pa�;y K D'aA 8ptb,'S. Ft _
pCAde} • T°p Bcwm
TOPOG,7APHIC/LAND SET'Inl,cheat e?pe�pia>e Ft—
i
OSApe Walley 4apallpid QC'�r 1I-DR;LLING LOG
LhTRU0. i B
To�— p ottom C CMS OR 3X��DD Formatijst� � "�
LONGiTL'Dl: -
-2MwM$OR 7x.===Cx DD J
LatifudeAongitude scur.,e: 165lmus (J'fopo9repl�ic Irray / —'
this de-a it Slid be BhOwn oa a USGS fap0 MOP aAd2L'sohed to
this Pour rfnc;using GPS)
S.WE OWNERLIZA—
TOwterName ^����—
S�Awdd —
Stale Tip Code ---�-- `
r J
keg:ode Phone number �.
6,WELL DETAILS: :• 12• REMARKS:
a. TOTAL DEPTH
b. ODES WELL REPLACE EXISTING WELL? "ES r, NOS...✓
G- WATER LEVEL Below Top of Caslryl I el
DOi lER'Egy CER?1FY THAT ITS W;LL WAS CQNS�
!;,hove a of �•eCbRDAIYCE 1W711 I5A NCAC 2C,Wp.I_L CON37RUCTION UcT`D 3N
P C?sigg STANDARDS,AND THAT COPY OF Trilg RECpF217 HAS BEEN
d- TOP OF CASING IS : PROVIDED TO THE VMLL OWNER,
'Top o!casn FT.Above i�ut SufaCe• �^^ r�
&terrtrn aror below tan#S C-rj a May_!ega lft / �Z —
KavdHa7ce iracCprdanGgvty s5A NCAO2C-G1Te. YIELD{gpj}- IGNATU RT P D Yd `HILTHOO OF TEST -7)DW R AVIS CONTRACTOR DATE
f. DISINFECTION.
Alitovnt : ORiNTEO NAME DF PZ SON CONSTRUCTING THE WELL
Submrivrsthsn 3t3 dey Of Corrlp(s#fDn tO:Divfsjon of Wafer Quailiy- lnformalion?r0oessing,
'8171'il:ail Set•vlce eigh,Cknler,Ral NC 2n99-151,phol :(819) QU2tllQ6
P°,i,I GIN-is
Rev,2109