GW1-2021-06302_Well Construction - GW1_20210915

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.. I `IDENV�'U WELL CONSTRUcrrOM RECORD
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North Carolina Department of Environment said Natural Resoumoes-Division ofjWekr Quality
911"° WELL CONTRACTOR CERTIF ICA.TIO Y hl
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1.WELL CONTRACTOR: g. WATER NbSnL,
TOIy'�Y DAVIS � 'i'pp'i,��"��IaiC lop f30ttOm
Well Contractor(Individual)Noma ;op #� Sotton� _ Top Battcm
DAVIS WELL BORING lop Bor:om Top Bottom
Weft Contractor Company Name
Thickness!
1, 81 LARRY DOIS ROAD r. CA G: Depth �Diameter Waljht material
S#raa�#Address~ f op 6ottorn 1.5 Cement
1 oPr,,,,,�,•„Batfon Ft'
City or Town State Zip Code
t 704t 276--3434 op 6ot'orr art. ,_,_
Area code Phone number S. GRQUT: Depth material Method
2.WELL INFORMATION: T)p {_%} Bo#totr 20 Ff. Ooncrete_ Truck
WELL CONSTRUCTION PERMIT# T sp__�,_,,,Bottom Ft.
OTHER ASSOCIATED PERMIT*(ff apptfcakls) T>p Bbttom FL
SITE VYEl.L ID ft{tf oppYceW.1 9, SCREEN: Depth Diameter Slot Size morial
3.WELL USE(Check doable Box): Residential V;ster SLppfy Ic— --; Top Bottom, Ft.. In. In.
DATE DRILLED ` ,� Tsrp bottom_ Ft. in. ` In.
TIME COMPLErED,r��_ AM❑ PM � Ttrp......._._Bottom_ Ft:, ,_,fn. aft.
4.WEL Lf3CATlON: tt.SANDIGRAVEL PACK:
.r Depth � t 8tze Material
ClTY: + cotatirrQJ= ; Tc�sonc�Ft. 9S—M Gravel
j J J'fr Tc p Bottom Ft,_,�
{Sweet Nfta Numbers, mmuntty uufsd on,Lot No. Pared,np Cade) Te p Bottom R,
TOP,DORAPFIiC I LAND SE•7`fINCa: (Owilt eppr midi bar.)
L3S)0pa pYaliey SI}lF C Os% pother 11. DRILLING LOG
"OP Bottom Fatmatfon Deacrtpda7
LATfNDC W—il, DMSOR 3x DO
LONGITUDE DMS OR 7 c.X 00=XX DD
Latttwfellonyltudo source: 03PS Qropographic snap -- V��•
occadon of well must be ShOWn on a USGS topo rnap andettached to
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this form It not using GPS) 1� ;,,sMXIA
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Ownfir Name
J n E,� k�fltt
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A.` J
S �{ �/re a
rat AdYlX
Cfly or Town Stat+ Zip Code
Area coda Mne number
12. REMARKS:
S.WELL DETAILS:
a, TOTAL OEPTH:
b, f70B8 WELL REPLACE a:X18T#NG YII)^LL4 YES C ND!!r" TOR HEREBY CERTIFY TEAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:,, FT. ACC ORDANCE WITH i SA uCAC 2C,WELL CONSTRUCTION
(Use`*'ff Abova Op of Casing STAVDARDS,AND THAT A COPY OF HIS RECORD HAS BEEN
a THE WELL OWNER.
d. TOP OF CASING is FT.Above land surface= %
*Top of casing terrilne ad at/or below land surfers mayrequire , I J �+4•� fJ '..G 4 f Gr
a ver#ance in aacordenee with 1 SA NCAC 2C.0`t8. : ; IATURE RTIF! C YrELL COM RACTQR DATE
a. YIELD(gpm): METHOD OF TEST TINY R DAVIS
f. DISINFECTION:Ty��� ount� j ; F RIATED NAME OF PER60 y CONSTiit1CT1Nr THE WELL
Submit within 30 days of completion to: Division of Water Qua.Ity - information Processing, form sui.
16'17 Mill Service Center.Raleloh. NC 7TnA9.19i Phnnn •iniot rlri9-atnr,