GW1-2022-10739_Well Construction - GW1_20221208

HIM
E'JIDE TLAL WELL CONSTRUCTION R.ECORT
North Carolina Dcpartmen:of Environment and Natural Reesso}urccss-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# �+�-(Y— 9
1.WELL CONTRACTOR: g. �yAJER ZONES(de th
TONY R DAVIS Top—yJ—/, —Bottom_ ,Tap Bottom
Well Contractor(individual)Name Top Bottom_ Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company'Name. Thickness/
1481 LARRY DAVIS ROAD 7. CAST G: Depth Diameter weight Material
Street Address Top Bono . Ft.24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.____I
City or Town State Zp Code Top_.T Bottom Ft._I
( 704 276-3434
Area code Phone number ___ 8. GROOUT: Depth _ Material Method
2.WELL INFORMATION: L. Top Cottom 20 Ft.­
_ COnCxete Truck
WELL CONSTRUCTION PER tvI T# : TopBottom Ft_
OTHER ASSOCIATED PERMIT#;if applicable)
Top Bottom Ft._
SITE WELL ID#(lf applicable) 9.;SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water.Supply� � Too Bottom, Ft. in. in.
` Top Bottom _Ft_�tn, in.
DATE DRILLED
TIME COMP•LE T,ED.-• _ AM❑ PIJ. _ .-.r.. ._ ._ ,•.__.. ..
p
To ; , • . ..Bottom :.• IIn. �
10 SANDIGRAVEL`PACK:
4.WELL LOCATION �• Depth ;Stze;;. Materiai
CITY: ® >, d �. ce I TY 1•op song Ft 7$=M Graver
f T op Boitort� Ft
( treat am-;NumSer3;Gcrnmu6dy'Sut>dN1s h.i Lot.N aral,Zip C ) titt�R1 Ft,_
TOPOGRAPHIC 1 LAND S ING (oho;k appropriate box) 11 DRILLING LOG .
❑S{ppe'`pvalley +❑Ridge :pother •Top Bottom Formation Description
CATITUQE ;,�,Z. OR 3X.X)OCXXXXXX DD
"� ,� I.�NIS OR 7X.)o=x XXX DD
LONGITUDE1
Lot tudeJiongitude source: BPS Qropographic map !
(location of well must be shown cn a USES topo map ardattached to
this form if not usingGPS}
5.WELL OWNER I OFb 0 8, 20 2
-1. ) -- � �.
xmratf
- !n`,_ �:Aga UrA
GAS:OiO
Clty or Town State Zip Code
Area code -Phone number 12. REMARKS:
6.WELL DETAILS: "; '
a. TOTAL DEPTH.
b; DOES WELL RSP:L'ACE EXISTING WELL? YES t7' NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c WAT!_R LEVEL Below Top of Casing:
1 r. ACCORDANCE WI 1 H 15A NCAC 2C;WELL CONSTRUCTION
(Use + rf hove i `p of Ca"sing) STAAJDARDS;,~ND.i Hf:T A COPY.OF THIS RECORD HAS EEEN-
WELL,OWNER.
-PROVIDED TO THE _
d. TOP OF`CAStNG IS; FT.Above'Land Surface' -
:,•..: � �
'Top of:c¢s,ng•tenrinate a! below Ian ati fa a tiiaytrequire '
a,variance in accordaki-n:with`15A NCAC 2C 0118: SFNATURIHO IFIE WELL,CONTRACTOP,:^.+ DATE
METH09 OF TEST TONI' R'"I}4VI.S
DISINFECTION: NL Type �pmouni n PRINTED IFAE OF PE,RSON.-GOPJSTRUCTiNG THE WELL
Submit within 30 days-of compjeti.on to:.Division;ref Water Quality- Information Frocessin!j, Fain GVV-ta
1617 Mail Service Center, Raleigh, NC 27699-161,Phone : (919) B07-6300 Rev.2109