GW1-2022-07528_Well Construction - GW1_20220811

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3k RE�IDENTW WELL CONSTRICTION RECOR.I)
ter`. r No th Carolina DcpW`traent of Environment and Natural Resourcfes--Divisionn of Wafers Quality
WELL CONTRACTOR CERTIFICATION#
g. VVATERA ZONES{de ):
1.WELL CONTRACTOR: ?op Bottom ToP Bottom
TONY R DAVIS
Well Contractor(lndividuai)Name Top Boriom Top
Bottom
DAVIS WELL BORING Top_ Bottom_ Top Bottom
Thickness!
lVei1 .ontraetor Company Name y',
1481 T.APPY DAVIS ROAD 7. CA NG: Depth Diameter Weight Material
Street Address Top BO:om6L Ft.—
24 I.5 Cement
LAIWNDALE NC 28090 Top Bottom Ft�
City or Town State Zip Code Top Bottom Ft•____
( 704 276-3434 8. GROUT: Depth Material Metiod
,Ljeacode Phone number 0 20 Concrete Truck
Top Bottom Fi._
2_WELL INFORMATION: s
Top Bottom FL_
WELL CONSTRUCTION PERMIT# Top Bottom Ft-
0 T PER ASSOCIATED PERMIT#V applicable)
SITE.WELL 1D#(ri applicable) S. SCREEN: Depth Diameter Slot Size Material
�: Top­Bottom Ft.__�in. in.
3.WELL USE(Check A pticable Bq"): Resi
0den'al'JVater Supply Top Sottom Ft in. in.
i
DATE DRILLED Top Bottom Ft.--In.
TIME COMPLETED IDAIM4e- M El
10.SAND/GRAVEL PACK:
4.WELL OCATION: t ��jt�1 Depth Size Material
cITY: COUNTY �i` ,TT°°'"' Top Bottom s.� Ft '78-M Gravel
Top Bot om Ft.
=v T op Bottom Ft.
(5treei Name,Numbers,GommunH• Subdivision,Lot o.,Parce,�p Code)
TOPOGRAPHIC/LA14 t ING: (cnecik appropnele boz) 11. DRILLING LOG
C Slope [Valley at G Ridge Q Other Top Bottom Formation Descption
LA.TrWDE _.. " "DIAS OR 3X.XXYJCXX>YX DD I
"D OR 7X.XXXXXXXXX DD ( —.
LONGITUDE
Latitudellongitude source: CAPS opographicmap
(locatiar.of v+ef!must be shown on a USGS topo map arrdatta;hed to
this form if not using GPS) 1 2Q22ER
-
5.W�ON �l /) P}/� I ♦ � �� n Qii1f r314c;1%CStr'nT+r';;r rLf>
Own
No ties/ -
Sir. t dd �
Cry or Town State Zi?Code /
Area code Phone number 12, REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: —
h. DOES WELL REPLACE EXISTING WELL? YES NO I DO HEREBY CERTFY. THAT T1A;S WELL WAS CONSTRUCTED IN
�FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATEF LEVEL Below Top of Casing: STANDARDS,AND Tr{A,T A COPY OF THIS RECORD HAS BEEN
(Use"+'if Above To!'Jor
o of Casing} PROVIDED THE WELL OWNER. 194
d. TOP OF CASING im T.Above Land Surf'Top of casing teminated below land surface may require '
a variance to accordance with 15A"aCAC 2C.0118. : SIG ATURE OF TiFIED WELL CON"RACTOR DATE
e. TOIdY R DAVIS
YIELD(gpm):
METHOD F TEST nt ELL
f. DISINFECTION:Type
� ou PRINT=u NAME Or PERSON CONSTRUC?iNu THE Vtr
Submit within 30 days of completion to: Divisio:z of Water Quality - Infornatior. Processing, Fora GVV I
Rev.2.w9
1617 Mail Service Center, Raleigh, NC Z7699-161,Phone :(919) BO?-6300

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