GW1-2022-01674_Well Construction - GW1_20220112

RESID.E.NT'UL wi�tJL CONSTRUCTION RECORD
* y
- North Carolina Department of Environment and Natural Rtsources-Division of Water Quaiity
WELL CONTRACTOR CERTIRICATiON#
1.'NELL CONTRACTOR: g. WAT ONES(de th):
T'OIvY R DAVIS Top Bottom QTap Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS kMLL BORING Top Bottom _ Top_ Bottom
Wel!Contactor Company Name
1481 LARRY DAVIS ROAD . Thickness/
7 CA NG: Depth Diameter Weight Material
Street Address Top `i Bottom Ft 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom Fi.
( 704_; 276-3434
Area Cade Phone number B. GROI:T: Depth t�r2terial Method
2.WELL INFORMATION: To C1 Bottom 2O Ft, Concrete Truck
I p
WELL CONSTRUCTION PERMIT �` S Q Top Bottom Ft.
OTHER ASSOCIATED PERMiT#(irappGcab)e) Top Boriom Ft.
Sri E WELL ID* f applimble) _ 9, SCREEN: Depth Diameter Slot Site Material
3.WELL USE(Check Applicab:e Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED ? __��� I Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PMQ" Top Bottom Ft. in. jr,.. _
4.NELL LOCATION: 1 .SANDIGRA.VEL PACK:
d Depth -size Material
aTY: c��:rraTYU� �fpar�aBattom�Ft. 78—M Gravel
dog k i4cl�Ne Top Bottom_ Ft.
(Street Nam m e, ubers,Cornmun Subdivislor.,Lot No.,Parcel,T.rp Code) ; Top Bottom Ft..
TOPOGRAPHIC/LAND S iNG: (ci=%,appropriate box)
:-iSlope oValley IJ at Ridge []Other1?.DRILLING LOG _
Top Bottom Forrr:atioG-Description-
LATITUDE rJIS OR 3x.XXxX)CX)CXX DD
LONGITUD w7f /�'� DMS OR 7X.VXVJO=DID !
Latitude.-7ongitude source: ZPPe- f Topographic map / �_ 'fi
OOCOfOn Of welt must be shown on a USGS topo map anda/tached to /
this form if not using GPSj
S.WELL OWNER /
Owner,NWe /
StPeet-Address "� - —
{ ftr/4 LAB 1
Cry or Town State Zip Coda /
Area code Phone number
B.WELL DETAILS: / 12. REMARKS:
a. TOTAL DEPTH.—
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0d---1`,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Se;ow Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•i€Above Top f Casing) STANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN
PROVIDED TO nE WELL OWNER,
d. TOP OF CASING IS FT.Above Land Surface• 1
'Top of casing terminated atior below lend surface may,.require
r20.0118.
a variance In accordance with 15A NCAC 2C.0119. SIGI ATURE OF (FIFO WELL CONTRACTOR DATE
e. YIELD(gpm): iETHO9 91:TEST TON.' R DAVIS
f. D!SlNFECTlON:Type ,Amount jt Itl PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing, Form G%N-1a
1617 Mail Service Center,Raleigh,NC 27639.161,Phone:[phone] Rev.2109