GW1-2022-08792_Well Construction - GW1_20220909

RESIDENTW WELL CONSTRLicTlorl R�COIt�
s2 Division.of%later Quality
North Carolina Department of En rorrnent and Natural Reso'ircl-ss,•
WELL CONTRACTOR CERTIFICATION
g. WATER 20
1.WELL CONTRACTOR:
ZONES(depth : Bottom
7ONY R DAVIS .; Top_0Botiom 1• ,�; ToR
Top,_ 3ottOm Top Bottom_ --
Well Contractor(indlyiduai)Name Bottom
DAVIS WELL BORING Top f Bottom ToP
Well Contractor Company Name Thickness/
1483 LARRY DAVIS ROAD 7. CAS NG: Depth Diameter Weight Material
S';reet Address
TOP Bottom Ft. 24 1.5 Cement
DALE NC 2E090 Top Bottom Ft._
Clay or Town State Zip Code : Top - _Bottom Ft•
70 276-3434 co 8. GROUT: Depth
Material Method
Area de Phone number. 0 9Oftom 20 FL Concrete Truck
2.WELL INFORMATION: l lf � Top —
WELL CONSTRUCTION PERM IT#a-+I `-�/!') ry Top Bottom FL
Top Bottom Ft-
OTHER ASSOCIATED PERMIT#(if spprcable)
SITE WELL ID#(if sppfirabte) 9. SCREEN,. Depth Diameter Slot Size Material
y�'- : Top_Bottom in. —
3.WELL USE(Check Ap fi ble Box): Residential Water SuP pl To Bottom Ft. Ire• in.
� Gn.✓
DATE DRILLED Top _ Bottom Ft in, in.
TIME COMPLETED AM O PM�
10.SANDIGRAVEL PACK.
4.WELL L ATION: : : .. A; Depth Size Material .
COUNTY Top V Bottom t 78-M Gravel
Top 80 bm Ft,'
Ft,.
(Street No e,Numt»rs,Comm y, u v s cn, o.,Parcel., P Co } Top Bottom
TOPOGRAPHIC/LAND SETTING: (check appmpriete box) . 11.DRILLING LOG
OSiope .C)Valiey DFiaf- ORidde [)Other Top Bottom Formation Description...
LATITUDE "DMS OR 3X.X*=,O XX DD
r "ryM5 OR 7X.XXX;Q(YY x DD t
LONGITUDE. _.— — ���
Latitude/longitude source: D3PS �raphic map
(location of well.must be sho,vn on a USG
S tozo map andatteched to I
this form if not using GPSJ I
ner Name
tAddress
City or Town State Zip Code
------
AreaC—)code Phone number 12. REMARKS:
6.WELL DETAILS: —
a: TOTAL.DEPTH: ;
b. DOES-WELL.REPLACE EXISTING WELL? YE5 Ci NOA': ,DO HEREBY CERTIFY THAT�THIS WELL WAS CONSTRU:TED IN
ACCORDANCEIh`ITN 15A NCAC 2C,WELL CONSTRUCTION.
c. WATER LEVEL Below Top of Casing: STANDARDS,AND THAT A COPY OF.THIS.RECORD HAS BEEIJ
(Use"+""if Above,T p of Casing) PROVIDED TO E WELL 01^i'NEFc.
d TOP'OF GASIlAG IS _.11+l�l FT.Above Land�Surface � /�
*.Top of casing terminated atJor below land surface may require �+
a'varianbe'tn accordance with 15A NCAC 2C.0118. SI TURF 0 TIFIED WELI CONTRACTOR GATE
e. YIELD(gpm):v METHOD OF TEST TONY IZ AVIS
L' aunt PRINTED NAME OF PERSON!CONSTRUCTING THE WELL
f. DISINFECTION7Type
Submit Within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
Rev.2lC9
1617 Mail Service Center, Raleigh,NC 27699.161,Phone:[phone]

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