GW1-2021-00279_Well Construction - GW1_20211213

1<ES DENTLAL WELL CONSTRUCTION RECORD
North Carolina 1Depar_nent of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WATER ZONES(de th1:
�jOIVY tZ DAVIS Top,.Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom _ Top Bottom
DAl'IS ±T L BORING
Top ,Bottom_ Tap Bottom
Wail Contactor Company tame
1481 LARRY DAVIS ROAD Thickness!
_ 7. CASING: Depth I Diameter Weight Materiel
Street Address Top, Bottom Ft 24 1.5 Cement
LAWIMALE NC 28090 Tep Bottom Ft —"—
CO or Town State Zip Code
( 70 276-3434 Top Bottom Ft.
ArEa code Phone number 8. GROUT: Depth Material Meth6d
2.WELL INFORMATION: , ` Top O Bottom 20 FL Concrete Truck
rJELr CONSTRUCTION PERMIT# yt'L71 Top Bottom Ft.
0-HER ASSOCIATED PERM T#(if applicable) Top Bottom Ft. _
SITE WILL ID.#(if applicable) S. SCREEN: Depth Diameter Slot Size Matoriai..
3.WELL USE(Check pliCabie Box): Residential Water Supply 0_� Top Bottom rt. in. in
DATE DRILL ED A^ 1 Top Bottom Ft. In. in.
TIME COMPLETED _ AM Ct PI,4�._...� Tcp Bottom Ff.. in. in.
4.WELL LOCA ON: - 10.SANDIGRAVEL PACK:
CITY: t a COUNTY 1e"��
Depth ,Sire Material
Q'� '( 7��;� : TopBoffom Ft. 7$—M Gravel.
o`lLp/V �O �, Top Bottom _Ft.
(Stree(Jame,Numbers, ommunity, uadivision,Lot No..ParcTop Bottom Ft. _
TOPOGRAPHIC]LAND SETTING: (cheek appropdata box)
,3Slope OValley oRidge ❑Other 11. DRILLING LOG
ag� ^ Top Bottom Formation Description
r1LATITUDE ��=2 DMS OR _X.XXXXX>000(DD J
LONGITUDE: i -," ^DMS OR 7x.XxYaOWocX DD
L atitudeliongitude source: []Topographic map )
(lOcae'On of well must be shown on a USES topo map andatteched to
this form it not using GPS) J
5.WELL OWNER J !
Owner Name u!_
Sir!-et Ad ress
94 or'fOwn Stale Zip Code J '
•1
: J
Area code Phone number
S.WELL DETAILS:
12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES
I DO HEREBY CER.iFY THAT THIS WELL N1 S CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT, ACCORDANCE 1hliTri 15A NCAC 2C,WELL CONSTRUCTION
(Use'+•if Above Top of Casing STANDARDS,AND THAT A COPY OF THIS RECORD F?AS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS t f,Avove Land Surface•
'Top of casing t=ordanc wh below land 2C.0surface may,require
a variance in accordance with t5A NCAC 2C.01 t8. mG NATURE�aF.'E�2TIFIED QLLO ~—TRACTOR DATE
METHOD e. YIELD(gem):_ METHOD OF TEST TONY R DAVIS
, PRINTED NAME OF PERSON CONSTRUCTING THE WELL
f. DIS±NFECTlON:Type(vrfa " Z Amount
i
Submitwithin 30 days of completion to: Division of Water Quality- Information Processing,
1617 Mail Service Center,Raleigh, NC 27696-161;Phone:[phone] 1 Form GW-ta
Rev.2%O8
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