GW1-2021-02481_Well Construction - GW1_20210607

t r 4 �\CSII�EN7'IAL WELL CONSTRUCTION RECORD
'� •'' North Carolina DepartmeA of Environment and Natural Resources-Division of Water Quality
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Msn 6
WELL CONTRACTO R.CERTIFICATION#_
1.WELL CONTRACTOR: g. T ZONES(d
TONY R DAVIS Top- Bottom-g�:�—; Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING : Top Bottum Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD _ 7. CAsi G: Depth Diameter Weight Material
Street.Address Top Bottom• 24 1.5 Cement
LAWI�TDALE NC 2 8090 Top Bottom Ft
ChyorTown Staia ZlpCode Top Bottom Ft.
t 704 t 276-3434 Material Method
Area code Phone number B. GRQUT: Depth
2.WELL INFORMATION:
Top U Bottom 20 Ft OOACfete Truck
WELL CONSTRUCTION PERMIT# .. Top Bottom Ft
OTHER ASSOCIATED PERMIT#(Sf applicable)
Top Bottom Ft.
SITE WELL ID#(•if oppricabie) J 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check ApplicableBox): Residential Water Supply Top Bottom Ft. in. In.
Top Bottom Ft in. in.
DATE DRILL Top Bohm Ft in. In.
TIME COMPLETED _ AM p PM
4.WELL LOC T10N: P10.SAND/GRAVEL PACK:
Depth atze Material
CI COUNTY Top_ ' sottom�t., 78—M Gravel
1 Arm
Top Bottom Ft
( treat%me,Num1mrs,Commun .SAxIinhMOTI,LaiNa.,Parcel,7.ip Code) Top Bottom Ft
TOPOGRAPHIC/LAND NG: (check appropriata box) 11.DRILLING LOG
OSlope E]Valley at ❑Ridge pother 'Top Bottom Formation Description
LAT�p -� ' DMS OR 3X.XXXXXXXXX DD /
LONGITUD 4-7� MS OR 7X.XXX)OCX)(XX DID /
Latitude/longitude source: JpW oropographic nap /
(location of well must be shown on a USGS topo mao andattachedto /
this fom7 if not using GPS) 1
5. L AWN R /
ner Name
pnss�inD knit
street A dress {}-C
/� �GOG40D
G� 1 .I]tl4 /V
C or Town State rip Code
/
Area code Phone number 12. REMARKS:
s.WELL DETAILS:
a. TOTAL DEPTH: ,/
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0� I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing FT. ACCORDANCE WITH A A COPY O,WELL CONSTRUCTION
(Use`+'if Above Top of Casing STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL 01A1NER
d. TOP OF CASING IS �F,.Above Land Surface*
*Top of casing terminates aUor below land sur+ace may require L•(
a variance in accordance with 15A NCAC 2C.0118. SI A�REIF27151�1CONTRACTOR DATE
e. YIELD(gpm): METHOD F TEST TONY R DAVIS
f. DISINFECTION:Type ount PRINTED NAME OF PERSON ONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality- Information Processing, Farm OW-1a
1617 Mail Service Center,Raleigh,NC 27699.161,Phone:[phone] Rev.2/09