GW1-2022-01297_Well Construction - GW1_20220112

IDENTUL WELL CotisTRUCTION RECORD
North Caralina Department of Environment and Natural Resources-
Division of Water Quality
WELL CONTRACTOR CERTIFICATION# I
9.WELL
CONTRACTOR-9- W 'TOM R DAVIS TO ER ZONES(depth):j
m
4VeIi Conuactor(individual)Name Botto Top Bottom Top Bottom Top Boron
DAVIS WELL BORING Top��6ottem Tom —
Well Contractor Company Name - r-�_Bottom
1481 LARRY DAVIS ROAD Thickness/
7. CASI G: Depth Diameter Weight Material
Stree<Addrass To ' 24 1.5 Cement
LAWNDALE NC 28090 p-�/ 3ottom�,FL`
City or Town Top, Bottom Ft
State Zip Code
704, 276-3434 Top Bottom Ft
—
Area code Phone number 8. GROUT: Depth Material M✓ethod
2.WELL INFORMATION: Tcp O Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#-.All� ^ , Top Bottom Ft.
OTiHERASSOCIATEDPERMT#('applicablel Top Bottom Ft..-
---
SITE WELL ID#(rf appfinble)
4, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. .in. in. _
DATE DRILLED ��-� j Top Bottom Ft. in. in.
TIME CCIlPLE-7ED AM Q PM Top-__Bottom
4.WELL LOCATION: � 10.SAND/GP,AVEL PACK:
CI?Y: COUNTY ,.1 Depth _-Size Material
Topes-0 Bottom ft. %8-I1
ravel
�1 Top_^_Bottom F=t.
(Scree Name,Numbers, omrrun'�,Subdi✓ ior.,Lof o.,Parcel,Zp Code) TpP Bottom
t.
TOPOGRAPHIC(LAND Sc T!NG: (cieck appropriate box) '
r'Siope CValley DRidge 00ther 11. DRtLL!NG LOG
LAT!TU� CjDMS OR 3X.XXXXXXXXX Dll Top Bottom Formation iJescriptlan
LONGITUDE: PAS OR 7X.XXXXXXXXX DD
Latitude/longitude source: QaPS F.''Tcpopraphic map
pocahon of well must be shown on a US6GS t000 mao a.ndaUached to
this fom:,f not using GPS}
5. OWNER
�ELL �Q �42. G
Owner Name
StreatAddress ' 4C� � M
C!ty or Town State .Zip Code J
L�J
Area code Phone number -�—
6.WELL DETAILS:
12. REMARKS:
a. TOTAL DEPTH: ^- _
b. DOES WELL REPLACE EXISTING WELL? YES._r, NQ — j
I DO HEREBY CERTIFY THAT THIS WELL WAS;:ONSTRUCTED iN
c. WATER LEVEL Below Top of Casing: IFT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUC710N
(Use'-'if Above Top of Casing} STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT,Above Land Surface`
'Top of casing teirnmzited a ®rbiow land surface may.requirer-a /1rJ-
S1Gj11ATU`REd;FtERTWiED a variance!m ac^ordance with t5A n!CAG 2C.G118. 'vELL Cf/C+NTRACCTTOR
e. YIELD(9pm).. METHOD OF TEST TONY R DAVIS )ATE
f. DISINFECTION:Type punt= PRINTED DAME OF PERSON CONSTRUCTING THc WELL
Silbmit With'ln 30 days of completion to: Division of Water Quality - Information Processing,
1517 Mall Service Center,Raleigh, NC 27699-161,Phone:[phone] Form c.1V-1a
Rev.Z109
i