GW1-2022-06485_Well Construction - GW1_20220706

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:-� =i RESIDE �". +'ELL CONSTRUCTIO\RECORD.
Noah Carolina Department of Environment and Nat ual Resources-Di rison of W atcr Qua?
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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g ONES(d t I
TONY R DAVIS � Top. W T ottom Top Bottom
Well Contactor(Individual)Name
Tap Boftcm, Top Bottom
DAVIS WELL BORING Top Bottom f Top Bottom
'Nell Contractor Company Name Thickness!
1481 TARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Top Bottom_ Ft.l 24 1.5 Cement
Steel Address
I�,WTiDA1/E NC 28090 Top Bottom Ft.±
City or Town State Zip Code ; Top Bottom Ft
t 7041 276-3434 8. GROUT: Depth Material _ Method
Area code Phone number. 0 20 Concrete Truck
• Top. Bo:?am Ft.� —
2.WELL INFORMATION: ,�j��v (�
■r�•� 1 4 (0 Top Boriom Ft.
WALL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable;
SITE WELL ID#(e applicable)) 9. SCREEN: Depth Diameter Slot Size Material
Bottom Ft. .in. in.
3.WELL.USE(Check Applicable Box): Residential Water Supply[ Top Bottom Ft--In. in.
DATE DRILLED �,`G• Top bottom Ft in, in.
TIME COMPLETED I AM PM R�r''
10.SANDIGRAVEL.PACK
4.WELL LOC ON: Depth Size Material
CITY: COUNTY (yL ? Top� Bottam��[Fl �8 Gravel '
Tope Bottom E
(St eel Name,Numbers.C mmunity,Su Met;,lot o.,Parcel.Zip Code) ?oF bottom Ft
TOPOGRAPHIC 1 LAND SETTING: (chaa(appropriate box) 11. DRILLING LOG
C,Slope pValley 31loo-6Ridge pOiher Top Bottom Foimationbescription
LATITUDE �C, . DMS OR 3X.XXYCOoOCXX DD /
?,a� DMS OR TX.X)o00cXXXX DD
LONGITUDEr�4 /
Latitudeiiongitude source: apre [Jro?ographie map r
(location of well must be shown on a USG S topo map andeftached to /--
this form if not using GPS)
S.VJELlL OWNER
Ot or lame
I'L�hsn< Unit
tAddress
City or Town State Zip Code 1
Area code Phone number 12. REMARIKS:
S.WELL DETAILS:
a. TOTAL DEPTH: :
b. DOES WELL REPLACE EXISTING WELL? YE.SW N0 0 I OO HEREBY CER=IPY THAT—THIS WELL WAS CONSTRUCTED IN
c. WA i ER LEVEL Below Top of Casing: 0.. FT ACCORDANCE WITH 15A N-AC 2C,WELL CONSTRUCTION
: STANDARDS;AWD TFL=T A C?UPY OF TH;S RECORD HAS.BEEN..
(Use`+'if Abov Top of Casing) PROVIDED TO.THE WELL OWNER
d TOP OP CASING IS` w�.
FT.Above Land Suiface' '
*Top bf`casing terminated atfor below land surface may require
-:a.variance in accordance with 15A NCAC 2C.011S. S1G ATLRE O TIRED VJcLL CONTRACTOR DATE
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e. YIELD(gpm): METHOD`OF'FEST" 'PONY R DAVIS
f. DISINFECTION,Type /�. Amount PRINTED tri4ME OF PERSONCONSTRUCTING THE WELL
Submit within 30 days CO i1 " dlVision of Water Quality Information Processing, Re"2109 1a
1617 Mail Service Center,Raleigh,NC 27699.161,Phone:(919}8U7