GW1-2022-10154_Well Construction - GW1_20221110

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RESIDED TR L WELL CONSTRUCTION RECORD
? te; North Carolina Deparbnent of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION
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1.WELL CONTRACTOR: U. WATER ZONES(depth:
TONY R DAMS Top_ Bottom_ Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contactor Company Name Thickness/
1481 LAR.RY DAVIS ROAD 7. CASING: Depth 'Diameter Weight Material
Street Address To Bottom_t Ft) 24 1.5 Cement
LAWNDALE NC 28090 Top BDttam Ft.'
City or Town State Zip Code Top Bottom Ft.
t 704 276-3434
Area code Phone number S. GROUT: Depth Material Method
2.WELL INFORMATION: : Top 0 Bottom 20 Ft. Concrete Truck
WILL CONSTRUCTION PERMIT# O \.2a2 2 ['741
L��� Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(It applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check A o11coble Box): Residential Water Supply Top Bottom Ft.' in. in.
DATE DRILLED Top Bottom FL in. in.
TIME COMPLETED _ AM❑ PMz.�
Top Bottom Ft. in. in.
4.WELL r r"'`110 10.SANDIGRAVEL PACK:
/� Depth size Material
., coulaNT 4j �: Top �b Bottom_ t' 18-M Gravel
Cl
Top Bottom Ft.
(Street Nam OoAgl
sion Lit No.,Pa I,zipg33
e) Top Bottom Ft.
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
0Slope OVal y OFiat ❑Ridge E]Cther 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE. __ XXXX^DMS OR _X. XXXXX DO J
LONGITUDE 7DMS OR 7X.XXXXXXXXX DO /
Latitudr3/longitude source: PS Dropographic map /
(focation of well must be shown on a USG S topo map andeffachad to
this fb"m if not using GPS) /
5.W 0 NER ¢m
Own ame
OMO S3L U .SI et Aao
City or Town State Zip Code J
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO!�
I DO HEREBY CERTIFY THAT THIS WELL WKS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casinp: �FT. ACCORDANCE WITH 15A NCAC 2C.WELL CONSTRUCTION
Pse°+°if Above To of Casing} STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL OWNER.
d. TOP OF CASING 1S FT.Above L and Surface'
'Top of casing terminated atlor e1Dw land surface may require 9�2�. 17
a variance in a rdance with 15A NCAC 2C.0118. SIG. ATURE R IED W CTOR DATE !�
e. YIELD(gpm): METHOD RIF TEST TONY R DAVIS
f. DISINFECTION:Type d&ount Z: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality . Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NO Z7699-161,Phone :[phone] Rev.2/09
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