GW1-2022-10151_Well Construction - GW1_20221110

= ,•, r. ; RESIDENTIAL WELL CONSTRLICTION RECORD
4 ch - '
V r J.v- v North Carolina Depanmcnt of Environment and Natty al Resovroes-Division of i stet Quality
WELL CONTRACTOR CERTIFICATION i; � i
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1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Top ottorrsrs_ Top Bottom
Weli Contractor(Individual)Name Top__Bottom Top Bottom
DAVIS WELL BORING Top ,_Bottom Top Bottom
Well Contractor Company Name
1481 Iy4RRY DAVIS ROAD i Thickness/
7. CASING: Depth Diameter Weight Material
Street Address Top Bothrr_6&I 24 1.5 Cement
LAWNDALE NC 28040 Top Bottom Ft
City or Town State Zip Code Top_Boriom Ft.
t 704_) 276-3434
Area code Phone number S. GROUT: Depth Matedal Method
2.WELL INFORMATION: ?—A /n : Top O Bottom 20 Ft: Concrete Truck
WELL CONSTRUCTION PERT# ! t Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(Ifapplirztile) Top Bottom Ft.
SITE WELL ID#(d eppllcable} 9. SCREEN: Depth DiametR Ed0sE j\&%
3.WELL USE(Check Applicable Box): Residential Water Supp;y Top Bottom Ft. in. �; in.
DATE DRILLED -1 � Top Bottom FL in,N7�U y 1 i0. zo22
TIME COMPLETED V AM p PM&/' Top Bottom Ft.;_ i Iin.
4.WELL L CATI N: 10.SAND/GRAVEL PACK: DW —
. 1 i1 Depth -Side Material
Cm: COUNTY LA/ Top �26 Bottom t: 78—M Gray el
Top Bottom Ft.
(Street Nam ,Numbers,Com unity,Subdivision,Lot No.,POW Tip C e) Top Bottom Ft.
TOPOGRAPHIC J LAN ING: (.-heck appropriate box)
❑Siope ❑Valley fat ❑Ridge DOther - 11. DRILLING LOG
Top Bottom Formation Descriptior.
tATR1iDE _-4MS OR 3X,XX�XXXX DO
LONGITUDE •- _ MS OR 7X.XXXXXXXXX DO
Latitude/longitude source: S )]topographic map
(location of well must be shown on a USGS tops map andatfached to
this form ff not using GPS)
5.WELL W ER �
�
dD CGS i
Ow. Name
c�n1c��S RU41
Stapept
ss
42eQ-Na A)c g2I I►. 1,
I U
City or Town State Zip Code f
Area code Phone number
12. REMARKS:
6,WELL DETAILS: '
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NQ06000, _
I DO HEREBY CERTIFYTHATTWIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:_a�� ) ACCORDANCE WITH 15A NCAC,2C,WELL CONSTRUCTION
(Use'+'if Above T pot Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(( PROVIDE TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface* !
'Top of casing terminated at/or below land surface may require R ��J ' )`�—_, , I
a variance in accordance with 15A NCAC 2C.01 18. 8XINATURE O CERTIFIED WELL CONTRACTOR DATE 7 �a
e, YIELD(gpm): METHOD F TEST TONY R DAVIS
f. DISINFECTION:Type J �1'tnount PRINTED NAME.OF PERSON CONSTRUCTING THE WELL.
Submit within 30 days of completion to: Division of Water Quality- Information Processing,
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Form-Ut 1a
Rev.21D9
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