GW1-2021-02508_Well Construction - GW1_20210805

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RRIIDENT L WELL CONSTRUCTION RECORD j
3" I Noah Carolina DeP ariment of Environment and Natural Resources.Division of Water Quality
WELL CONTRA{-TflR CERTIFICATION# =- �c+'
1.WELL CONTRACTOR: g. WATER ZONES(de }:
TONY R DAVIS Top.a!7 Bottom TOP. Bottom
Well Contractor(Individual)Name ; Top Bottom Top Bottom
DAVIS WELL BORING Tap Bottom Tap Bottom
Well Contractor Company Name
1481: LARRY DAVIS ROAD Thickness/7. CASING: Depth Diameter Wei ht ht Material
Street Address TO Batta Ft. 24 1.1 Cement
LAW10ALE NC 2$090 Tap Bottom Ft C
City or-Town Slate Zip Code Top Bottom Ft,
t 704 276-3434
Area coda Phone number B. GRQUT: Depth Material Method
2.WELL INFORMATION: Top. U Bottom 20 ft. jOriCTete Truck
aWELL CONSTRUCTION nRMiT#� Top Bottom Ft,
0 T HER ASSOCIATED PERmrrt-(ir,a*ieable) TO Bottom Ft
SITE WELL ID#{it sppGgble) 9;SCREEN:• Depth Diameter Slat Size Material
3.WELL USE(Check Applicable Box): Residential plater Supply Top Bottom Fr. .In. In.
DATE DRILLED !7 _4.— f' Top Bottom F4 in. in.
TIME �COMPLETED t- �� AM❑ PMAr
Top Bottom Ft. !n.' In.
3.WELL LOCATION: `10.SANDIGRAVEL PACK:
CITY:�,a f • ' AUNTY i:� '� Depth ,5tze Material .
/ To, j/��,�-BoftDla►a Ft.., 7$-M Gravel
2 5`O 2 / Top - Bottom Ft
(Street Name,Numbers,Commurft Subdivision,Lot No.,Parzael,Zip Code) Top Bottom Ft.,
TOPOGRAPHIC t LAND SETTING: (chea'approprfabr bek)
OSlope DValtey Iaftf'pRidge pother 11.DRILLING LOG,
/
LA'Tf[UDEr � ��fe<<��MS OR 3.C.YJCXXXXXXX DO Top Bottom Formation Description
x
LONGITUDE . j "DMS OR T.S.Xf OM.V 0(DD
Lathudellongitude source. Aspr0ropographicriap !
(loceffon of well must be shown on a USGS topo me; andeffaahedto 1
this farm if not using GPS)
5.Vii LL OWNER zi
Name ,
S Address
ity or Town state Zip Coda / C�0Pl
Area code Phone number
8.WELL DETAILS: 12..,REMARKS::
a. TOTAL DEPTH.C1 _._ ...
b. DOES WELL REPLACE EXISTING WELL? YES ] NO(�►'"'�
r I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED,IN
c. WATER LEVEL Below Top of Casing: � F T, ACCORDANCE 1NITH 15A NCAC 2C,WELL CONSTRUCTION
(Use t rfAboveT- --�----sing) TANDARDS,ATHE ELL"OWNER THIS RECORD HAS BEEN
5P.10POF
d.TOP OF CASING is FT.Above Lan Surface ,
Surfac
'Top 4f casing terminated et/or below land surface tnay_require.
a variance in acdordance with 15A NCAC 2C.0,19.
SIGNATURE ERTIFtED WEL�CONTRACTOR DRTE:: -
e. YIELD(gpm): "OD OF TEST, �� TO-NY R DAVIS � I
f. DISlNFECTIQN:TYPsp
Amourrt. PRINTED NAME OF PERSON CONSTRUC I"ING THE WELL
SubmitvAth€n 30 days of completion to: Div.sion of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-1fii,Phone:(919)SOT-6300 I, Rev,2109