GW1-2022-10196_Well Construction - GW1_20221111

'
s a RESIDENTIAL «IJLL CORD
CONSTRUCTION.
1 may'• Qs North Carolina Department
Envirormert and Natural P,esources-Division of Water Quality
'�a•••�" ' WELL COIVTRAC'i'OR CERTIFICATION
g. WATER ZONES(de th):
1.WELL CONTRACTOR: _�Bottom 10p Bottom
TO">I' R DAMS _ Top
Well Contractor(individual)Name Top Bottom.I — Top Bo tom
DAVIS WELL BORING Top Bottom Top _Bottom _
VNe:l C-ontractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter weight Material
Street Address Top Bottom L/ev--t­TQF
2 •5 Cement
LAW_NDALE 24C 280990 Top Bottom ' Ft•
C"ttyr or Town State Zip Code Top—Bottom Ft.
104; 276-3434 _ Material Method
Area code Phone number 8. fSRO4 T Depth
2.WELL INFORMATION:
Top 3ottom 20_ FI. Concrete Truck
/L Top Bottom Ft
WELL CONSTRUCTION PERMIT#
Top 30ttom Ft.
OTHER;.SSOC+ATED PERMIT#(if applicable)--
SITE WELL ID#(e applicable) 9. SCREEN: Depth Diameter Slot Size Material
Top -Bottom Ft. In. in.
3.WELL USE(Check Applicable Box): Residential Water Supply
�» ^ f� Top Bottom Ft. n.in. i
DATE DRILLED r Top Bottom 1 t in. _ In. _
T1ARE COMPLETED 'i � — Alvj�r'P1C"b
10.SANDIGRAVEL POCK:
4.WELL CATION: Depth -Size Material
CITY: aS ZoeL C%AUNTY ��: Top-V ac'torn_ i. 18-M Graved --
n � A /y?� l ' Top____�Bottom ' Ft.
Sveei ame, um ers,Community,Subd!w;aon,Let Mo..Parcel,Zip COde Top Bottom C' _
TOPOGRAPHIC'LAND S5 ING: IChe:ac appropriate box) 11. DRILLING LOG
CSlope rValley d /�GRidge C)Other Top Bogom Formation Description
LATITUDE a�:l�-" .(1��MS OR DO
LONGITUDE CMS OR 7X.XXXXXXXXX DD - ,t-�� RXI
>_etttude>llongitude source: Pn P P /
(1ocaL�on of wet;must be shown on a USES topo map andaftached to r NOV 1
this form if not using GPS) — _
J
S.WELL OWNER 4 f' is:t�'t Pr;ic $Ur►A
�.�
Owner Name �� �, � � J �•a _ -
-Sc',reet Address _
City or Town State Zip Code
Area code Phone number 12. REMARKS:
6.WELL DETAILS: L
a. TOTAL DEPTH: _
b. DOES WELL REPLACE EXISTING WELL? YES C NO
100 iti REBY CERTIFY':-I.ST THIS WELL'WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: , FT. .ACCORDANCE WITH 15A NCAC 2C,WELL CONS TRU;TiON
(Use"+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD PAS BEEN
PROVIDED TO THE SELL OWNER.
d. TOP OF CASING IS " _I7.Above Land Surface'
`Top of casing terminated atlor below land surface may require
a vaeance in accordance w;th 15A NCAC 2C-0.16. S1G ATURE F CE i1 iED WELL CONTRACTOR DATE
e. YIELD(gam)' METHOD OF TEST_ TONY R DAVIS
f. DISINFECTION:Type noun ; PRINTED NAPJ E OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- informationlProcessing, Fora CW-Ia
1617 Mail Service Center, Raleigh, NC 27699-161,Phone:{919)807-6300 Rev,2/09