GW1-2021-02107_Well Construction - GW1_20210706

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REStDENT1AL WELL CONSTRUCTION ItEC+oRD JUL
f North Carolina Depart vent of Environment and Natural Resources-Division of Water Quality Unit
9".4 er of 1 w n(anrat'ton se"fO n0
WELL CONTRACTOR CERTIFICATION# it Se�tlan
t.WELL CONTRACTOR: g. W ER ZONES(de th:
TONY R DAVIS Top. Bottom, QQ. Top Bottom
Weil Contractor(Individual)Name ; Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom ' Top Bottom
Weil Contractor Company Name i Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom
�Ft 24 Cement
LAWNDALE NC 28090 Top Bottom Ft
.City or Town State Zip Code : Top Bottom Ff.
( 7041 276-3434
Area code Phone number 8. GROUT: Depth Material Method
O Bottom 20 _Ft. Concrete Truck
2.WELL INFORMATION, *j /�� Tap
WELL CONSTRUCTION PERMIT06 �W "0 C' 1 Top__-__,,,_Bottom Ft.
OTHER ASSOCIATED PERMIT#(ifmWceHe) Tap Bottom FL
SITE WELL ID#(rr appricable} 01
�_.r 9. SCREEN: Depth lameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Lam- Top Bottom Ft in. in.
DATE DRILLED " " Top Bottom Ft in. in.
: -.Top: Bottom Ft. . in, in.
TIME COMPLETED ,AM C 'S't�1
SANDIGRAVEL PACK:
d.WELL L4CATiON Dept giZe Material
CITY: " , ► c rr( op ottom. t 78 m, Gravel
Tap' Bottarh Ff "
me,'Num Top . Bottom
.C mm S 'st ,Lot o• Parcel, p } `
TOP0 PHiC 1 LAND SETTING: (cheer Wm;iriati box)` ,
pe DValley ❑Flat ORldge pother 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE+ ,r � MS ORX.XXXXXX70Dt DD
LONGITUDE ". _6 "DM5 OR 7X.XX)0(XXXXX DO
Laftde/iongitude source: @81PC-DTopographie reap /
(location of well must be shown on a USGS topo map andeffached to /
this farm ff not using GPS) r
Owner Name /
trsetAdd
72
1.1 /
City or Town Stags Zip Code /
Area code Phone number :• 12., REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 6
b. DOES WELL REPLACE EXXISTiNG WELL? YES p NO
.ID DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top.of Casing FT. : .'ACCORDANCE WITH 15A NCAC 20 WELL CONSTRUCTION.:
(lase'+"if Above Top of,Casing} STANDARDS,AND THAT A COPX.OF THIS RECORD HAS-SEEN
PROVIDED T THE^WELL OWNER /
d.1TOP'OF CASING iS ~L= FT.Above 1-1nd Surface
:.-TOP of casing terminated attor"belowJand surfs:s.may`require J R
a variance in accordance with 15A NCAC 2C.(118. SIGN TURE OF IFIED ELL CO ACTOR " DATE
e. YIELD(Spm): METHOD-OFTEST_::_. - TONY % DAVIS-
t. DISINFECTION:Type44QW+0.rtrount-` l2 PRINTED NAME OF PERSON CONSTRUCTING THE WELL
SubmityAthin 30 days of Cofnpletion to:Division of Water Quality- Information Processing, Farm GW 1s
1617 Mall Service Center,Raleigh,NC 27699-161,Phone:(919)80T•6300 Rev.2i09