GW1-2022-01298_Well Construction - GW1_20220112

ON STRU CTI—O—N—R�ECO RD,'
`WLtei
Resuurces-Division of Qualit"
j
NTorth Caralin a DepaitmtV t of Environment and Natural
WELL CONTRACTOR CERTIFICATION 4
g. WATER ZONEth)*
1.WELL CONTRACTOR: Bottom' dnk 'Top_BOttOrn-
TORY R DAVIS ---4— _
Well Gonvacior(Individual)Name Top_Butt0l'1 Top Bottom
DAMSLYELL BORING 1--
Top._ Bottom_ Top---Bottom—
Thickness)
Well Contractor Company Name Bo tom
7. CASING: Depth Diameter Weight mate-lial
1481 ARRY DAVIS ROAD lzlf�Ft. �24 1.5 Cement
Street Address Tol:,4�4
LAWNDALE NC 28090 Top_Bottom_FL_
C`;tq C,r Town State Zip Coda Top_Bottom—Ft,
(_7014) 276-3434 Method
2.WELL INFORMATION: Top Bottom Area code -Phone number 8. GROUT: Depth Material
T, 20 Ft. Concrete Track
— —
WELL CONSTRUCTION PERMITI�.—'A—I --0 /9q-&St-- Top-BC'tlDm—Ft-
Top—Bottom_Ft.-
OTHER ASSOCIATED PERMIT#(tf applicable)--
SITE WELL ID 9(if applimble) 9. SCREEN: Depth Diameter Slot Size Material
Top__Bottom_Ft. in. — in.
3.WELL USE(Check Applicable Box): Residential Wafer Supply
0— Top_Bottom_Ft in. ­ in.
DATE DRILLED . 1
Top--Bottom—Ft. in. _ In-
711ME COMPLETED AM 0 RM�-.
10,SANDIGRAVEL PACK:
4.WELL LOCATION' Depth -size Material
CQUNTYIZ�e /� ToD.2Q..srLom's-5�Ft. 78-M Gravel
007 Qq Top_30tt0rn­—Ft
'�mmun Subdil��F.b. t No.,Parcel
kstreat 4,aNum�ws.�C----n Top_Buttom
TOPOGRAPH!C/LAND SETTING: (dheck app-m0aie box) 11.DRILLING LOG
C)Slop-- DValley ififtir []Ridge 00ther. Top Bottom Formation Description
f,,rVS OR 3?L.V"XXXX DO
IA�j 12
LONGITUDE - DMS OR T�-XXXXXXXXX DD
Latit,idefsongitude source: W.Peloropographic InSP
(location of well must be shown on a USGS tope n7ad andattached to
this form it'not using GPS)
5 WELAY3NER
Owner Name
/000
Street Address
02-sj, C
City or Town Stzte Zip Code
Area code Phone number 12. REMARKS:
S.WELL DETAILS:
a. TOTAL DSPTH.—S-IF
b. DOES WELL REPLACE EXISTING VIELL? YES 0 NQ46"' TDO—HEREBY CERTIFY—THAT THIS WELL WASCONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1 SA NCAC 2C WELL CONSTRUCTION
kUse'+*if.Ab T OfCasing7
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL OWNER.
d. TOP OF CASING Is FT.Above Land Surface"
of casing terminated attor below land surface may require
a variance in accordance with 15A.NCAC 2C.0118. $I(32NATURE Ol?"CERTIFIED WELrCONTRACTOR DATE
ETHOi F TEST TONY R DAVIS
e. YIELD(qpm):
I M /69 Amount PRINTED NAME OF PERSON CONSTRUCTING HE WELL
f. DISINFECTION:TypMaGlow
SubmiltvAthin 30 days of completion to: Division of Water Quafty- information Process Ing, Form GW-1 a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone :[phone] 1 Rev.2109