GW1-2021-00467_Well Construction - GW1_20210210

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rSRESjDE'VIIALWELLCO\STRi!CTIO�� RECORD
Nonl:Ca:ol:r.aDepartment of Erviror:mcnt andNatira:Resources-Division cf Watc.Quaiity
�+ WELL CO:vTRACTOR CERTIFICATION
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Top-Zw_Bottom '�_ Too Bo5cm,___
'Nell Contractor(individual)Name ToD Bottom _ Top__Bottom_____
DAVIS WELL BORING Top _Bottom Top__.Bohcr
,,%ell Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom, GG Ft, 24 1.5 Cement
Lk'WNDALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft.
7041 276-3434
Area code Phone number I 8. GROUT: Depth Material Vethod
i Top 0 Bottom 20 FL Concrete Truck
2.WELL INFORMATION: ee�� e�.�
WELL CONSTRUCTION PERMIT#-�o`0 ^ jll ljl 1- + 'op Bottom Ft.
_
OTHER ASSOCIATED PERM!Tt('R eppliceoie) _ Tcp Bottom 'rt.
SITE LVEL.ID&Cd appGriSie; 9, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check A llcab:e Box): Residential:"ia.er Supply�'�: Top__Bottom °t.,—in. in. _
Pr II
DATE GRILLED�� d TopBotom Ft--in- in.
Top Bottom Ft.—In. In,
TIME COMPLETED
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
rt Depth Size Material
,,r,U,(.j�.e (:OUN1 7rH 4 Top�BoHom Ft, 78—M Gravel
Top Bottom Ft.
rSVae4 Nama,h'umbars,CommunRY,SI+bdM510n,Lot No.,Parcel,Dp Code) Top Bottom_____Ft.
TOPOGRAPHIC'LANDSETTING: (chuck appmoige box) 11 DR!LUNG LOG
=.Slo?e CVailey lilt t�Z/ Riiddg'ee 00ther Top Bottom Fomration Dascdption
L ATITUDE DMS OR 3X.XXXXXXXXX DO
LONGITUDE ,2 .-J DMS OR 7X.XXXXXXXX% DO / -
LatiFideAongnudescurce: 1-7F sPs' CrOPograPhicmap /
pocabon of well must be shown on a USGS tcpn mac andattached to
:his forth ifnot using GPS,$
5.WELIg.WNER
wzy a
owner Name
--
C1y or Town State Zip Coda
Area code Phone number 12. REMARKS:
6.WELL DETAILS: ---
a. TOTAL DEPTH:__ � -- —
b. DOES WELL REPLACE EXISTING WELL? YES-0—NU] DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED!N
o. WATER LEVEL Below Top of Casing'_ __FT. ACCORDANCE W17H 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use'+'if Above Top of Casing) PROVIDED OTHE WELL O\NNER.
d. TOP OF CASING IS��__ FT.land
su Land Surface' i/� n, . / "r �� 1
'Top of casing temllnated aVor below land su(ace may require /�7� ��[ KJ C.��'�-11
a vadance in accord ice w;'h 15A NCAC 2C.0118. SSIGNATUR CERTIFIED NiELL CONTRACTOR
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type e- Amount PRINTED NAVE OF PERSON CON'STRUCT;NG THE Vv'ELL
Submit Within 30 days of completion to: Division of Water Quality- Information Processing, corn GW-1a
1617 Mall Service Center,Raleigh,NC 27699.161,Phone :[phone] Rev.2/09