GW1-2022-10741_Well Construction - GW1_20221208

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ES'd�E1V_TZ4Z WELL CONSTRUCTION REC�ORD
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North Carolina Department.of Environment and Natural Reso-arces-Division o water Quality
WELL CONTR4,CTOR CERTIFICATION O
1.WELL CONTRACT OR: g. YA ERZCNES(d
TOI4I' R DAVIS Top Bottom Top Bottom
We!I Contractor(Individual)Name Top Bottom Top Sottom
DAVIS WELL BORING Top _Bottom_ Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CA IN : Depth Diameter Weight Material
Street Address Top:Bottom' 24 1.5 _ Cemen,
UWNDALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom FE.
( 704, 276-3434 _
Area code Phone number S. GROUT: Depth Material Method
2.WELL INFORMATION: +� Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#;2,q J Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(ff applicabla) Top Bottom Ft.
SITE WELL ID#Cd applicable} 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply p Top Bottom Ft, in. in.
DATE DRILLED Z Top Bottom F1', in. in.
TIME COMPLETED _ AI~4 p P
Top Bottom F:•. in, in.
4.WELL LO ATIO 10.SANDIGRAVEL PACK:
/� Depth -Size Material
CITY: COUNTI _�� � To �-+ Bottom } 78-1`) Gravel
�CC7Top Bottom Ft.
(Street.Name, um ors,Communi y,Subdv?non,Lot Ro..Par p Code1 77Top Bottom—Ft.
TOPOGRAPHIC/LANDS IN G: (check appropriate box)
0slope pValley at oRidge O ther 11.DRILLING LOG
Top Bottom Formation Description
LATIT'JD D S OR 3X.XXXXXXXXX DD
LONGITUDE- PAS OR 7X..XXXXXXXXX DD
Latitudeliongituds source:dPFI Ol opographic map
(!ocabbrl of well must be shown on a USGS topo map andattached to
this fomr if not using GPS)
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honer 1a �
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(�r:G=�,v^n.S�iJ 'A
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S•ee Address �—
City or Town — Zip Cade
Area code Phone number
: 12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES N0�
1 DO HEREBY CERTIFY THAT THIS WELL W.AS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE 4AATH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•if Above Top of Casing) STANDARDS,AND THAT A COPIY bF THIS RECORD HAS BEEN
�,, l PROVI THE WELL OWNER.
d. TOP OF CASING 15-- - FT.Above Land Surface' A '9-0,
•Tap of casing teminated 3tior below land surface may require '
a variance in accordance with 15A P1CAC•2C.0118. SIGNATURE CERTIFIED' LL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Typ Amount PRINTED KNOE OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to; Division of Water Quality- Information Processing; For,GW-ia
1817 Mail Service Center, Raleigh,NC 27699.161,Phone:[phone] Rev.2/09
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