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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 Q tty 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