GW1-2022-01291_Well Construction - GW1_20220112

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RESIDENTIAL WELL CONSTRUCTION RECORD
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- ' North Carolina Oepaatrnert of Environment and Natural Resourccs-Division of Wexr Quality
" . s.•r`¢ WELL CONTRACTOR CERTIFICATION
1.'rVELL CONTRACTOR: g. WAT ONES(de th):
TONY R DAVIS Top ±4Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS U7ELL BORING Top Bottom Top_ Bottom
Well Contractor Company Name
Thickness/
1481 LARRY DAVIS ROAD 7. CA NG: Depth ;Diameter Weight Material
Street Address Top11 9ottomFt! 24 1.5 Cement
NC 28090 Top Bottom Ft'
Cit/or Town State Zip Coda Top Bottom Ft
( 704: 276-3434
Area code Phone number 8. GROUT: Depth Rteterial Method
2.WELL INFORMATION: 1 Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#,­�.2 ( ' "1✓J CIO Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(inapplicable) Top__Botlorr Ft.
SITE WELL ID*(if applicable) _ 9, SCREEN: Depth Diameter Slot Site Material
3.WELL USE(Check Applicable Box): Residential'Alater Supply 9-"' Top Bottom Ft. in. in.
DATE DRILLED ;1 () Top Bottom Ft. in. in.
TIME COMPLETED AM p PM4
Top Bottom Ft. in.
4.-NELL LOCATION: 1 .SANDIGRA.VEL PACK:
Depth Etze Material
CITY:
. (; a,urJr,�� p��!BottomFt.' 78—M Gravel
Y �A ..�2 � Top Bettor_ Ft.:
(Street Name,Nurrib6rs,Community,Subdivision,Lot No.,Parcel,Zip code) Top Bottom Ft-
TOPOGRAPHIC l LANDS ING: (chock appropriate box)
Lislo a civalley C0157' . Ridge Other I!.DRILLING LOG
Top Bottom Formadon-D'escriptiorr-
XX .
LATITUDE �+ RMS OR 3X. VAXXXX DID
LONGITL DE+ F DIAS DR 7X.VAnoo=DD /
Latituds1ongitude source: opograpNc map / °-
f1c,cadon of well must be shown on a USGS topo map anda+fached to /
this farm ft not using GPSj
S.WELL OWNER
Owner e
S t Address
")zAe --
C or Town State Zip Code — J
U /
Area code Phone number
12, REMARKS:
G.WELL DETAILS:
a. TOTAL DEPTH: _
b. DOES WELL REPLACE EXISTING WELL? YES] N0�
I DO HEREBY CERTIFY TIHAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing._ 1 `fr --FT. ACCORDANCE WITH 15A NCAC;2C,WELL CONSTRUCTION
(Use"+•if Above Top f Casing) STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN
PROVIDED TO FE'JdELL OWNER.
d, TOP OF CASING IS �Fl•.Above Land Surface' i
'Top of casing terminated allor below land surface may,require
a variance In accordance with 1SA NCAC 20.0118.
Slv!ATURE OF-OWTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 4ETHOD qF TEST TON. Ri DAVIS
f. DISINFECTION:Type Amount�,� PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of Completion to: Division of Water Quality- Inforrnation Processing, Form GW-1 a
1617!'flail Service Center,Raleigh,NC 27699.161,Phone:[phone] Rev.2!0e