GW1-2022-07548_Well Construction - GW1_20220815

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/�/%�sy C ` RESIDENTIAL «'ELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CON RACTOR CERPiFICATION#
1.WELL CONTRACTOR: g. TER ZONES(de ): i
TONY R R A TO Top Bottom Top Bottom
Well Contractor(individual)Name Top_ Bottom ToP Bottom
DAVIS WELL BORING Top_ Bottom— Top_______Bottom_
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASs G: Depth Diameter Weight Material
Street Address
Topm Bottom Ft. 24 1.5 cement
aAWNDALE NC 28090 Top Bottom Ft. -
City or Town State Zip Code Top Bottom Ft•
L 704� 276-3434
Area code Phone number 8. GROU T: Depth Material Method
2.WELL INFORMATION:
Top 0 Bottom 20 Ft, Concrete Truck
WELL CONSTRUCTION PERMIT#�
Top Bottbm Ff.
Top Bottbm FL .._.--.—
O T HER ASSOCIATED PERMIT#(if applicable;:
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
lop Bottom Ft. •In. In.
3.WELL USE(Check Applicable Box): Res dentiat Water Supply L�!' Bottom Ft. in. in.
2 Top
DATE DRILLED lop Bottom Ft. in. in.
TIME COMPLETED _ AM❑ P
10,SANDIGRAVEL PACK:
4,WELL LOCATION: Depth alive Material
U C;7f �'t�. --COUNTY a Top O Bottom Ft` 18_M
�,.1,L/ ,fit - Gravel
Top . _Bottom Ft.
(Street Name,Numbers,Cornmundy;Su iviston,Lot No.,Parcel,Zip Code)' Top—so.` ttom Ft y
TOPOGRAPHIC,/-LANDS ING: (check appropriate box) 11.DRILLING LOG
p Slope p`Yailey / p Rid e'p Other 'Top Bottom Formation Desedption
LATITUD / "DMS OR 3Y,.XXXXXX)Xu DID L .
LONGITUDE S OR 7X.XXXXXXXXX DD / ;—t�•-•}p
Latitudellongitude source. Qropographic map
(location of well must be shown on a USGS topo map andaitached to
this form,If not using GP$) �
5,WE NER ! 5,�7.r.�r,� t?g Ur►it
er N 2:8 � is how
,S:reet Ad ress
City or Town State Zip Code /
/
Area code Phone number 12. REMARKS:
6.WELL DETAILS: 1
a..TOTAL DEPTH:
b. 'DOES WELL REPLACE EXISTING WELL? YES O N0 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c:WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NGAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'+!d Above To of Casing) PROVIDED TO THE WELL OWNER.
;&: TOP.OF CASING Is —FT Above Land Surface :
--*Top of casing terminated attor"below land surface may require _
a-variance in accordance with 15A NCAC 2C.0118. SIGNIATURE�O7TRACTOR DATE.
e TONY R DAMS
YIELD(gpm. METHOD O�.Amount PRINTED NAME OF PERSON C
f. DISINFECTION:Type _-7 �� ONSTRUCTING THE'WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Fora,GW-1a
Rev.2/:)9
1617 Mail Service Center,Raleigh,INC 27699-161,Phone:[phone]