GW1-2022-10740_Well Construction - GW1_20221208

bt. RR'UDE1�TraU WELL coivST:RuerIONRECORD
Noah Carolina Department of Environment and Natural Resources-Division of 'Water Quality
WELL CONTRACTOR
RA TOR CERTIFICATIQN#
1.WELL CONTRACTOR: g. A (d }';
TONY R DAVIS Top-�+TE ZONES Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name
1481 LAR_RY DAVIS ROAD Thickness/
7. CASING. Depth Diameter Weight Material
Street Address Top B It
om It 1 24 1.5 Cement
LAWNDALE NC 28090
Top­_Bottom Ft.
City or Town State Zip Code
704) 276-3434 Top Bottom Ft.
Area code Phone number B. GROUT: Depth Material Method
2.14'ELL INFORMATION: Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#r TOP Bottom FL
OTHER ASSOC IATED PERM[TV applicat+le) Top Bottom Ft.
SITE WELL ID#(dappticable) S. SCREEN: Depth Diameter SlotSlze Material
3.WELL USE(Check Applicable Box): Residential Water Supply if—'� ; Top Bottom Ft, in. in.
DATE DRILLED-/ ToA Bottom Ft,. tn. in,
TIME COMPLETED �Z36 AM D PMC;:.� Top Bottom Ft in. in.
4.VYELL O ATION- b 10.SANDIGRAVEL PACK:
/ Depth Size Material
c1TY: cFouNr 46� Top BottoWk��Ft. 16—m Gravel
Top Bottom Ft.
{Straw! me,Numbe r ComMU.My,Subd 'Sion,Lot No.,Parel,Tip ode Top Bottom Ft.
TOPOGRAPHIC 1 LAND�S �ING: (check appropriate bmx)
LiSlope pValley $W ❑Ridg 0Other 11.DRILLING LOG
'Top Bottom Formation Description
L4TfTU0W- L-4�1
"UMS OR 3X.XXXXXXYXXX DD
LONGIT "DMS OR 7X.XXXXXXXXX DO /
Latitudellongitude source: S Dropographic map
(location of well must be shown on a USGS topo map andattaahed to
this form if not using GPS) -
S.WELL OWNER e� ®' "" `"j
kgs&cv n.FC a-98-2029
Owner Name
S1 tAddre S
Cdy or Town State Zip Code
Are code ode Phone number /
A.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:
1
b. DOES WELL REPLACE EXISTING WELL? YES NO❑
s I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
e. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC1.6,WELL CONSTRUCTION
(Use'+'if Above Top of Casing} STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNEtR)
d. TOP OF CASING IS Fi-.Above Land Surface'
'Top of casing terminated atror below land surface may require —ar
a variance in accordance with 15A NCAC 2C.0118. siGNATURE OF'iE4§TIFIED 'EPONTPACTOR
DATE
e. YIELD(gpm): M"ODOFST TONY R DAVIS
f. DISINFECTION:Typeout PRINTED NAME OF PERSON CO I STRUCTING THE WELL
I
Submit within 30 days of completion to: Division of Water Quality- Information Processing,;
1617 Mail Service Center,Raleigh,NC Z7698-161,Phone:(919)BD7-6300 Form 1D9
Rev.21119