GW1--01597_Well Construction - GW1_20240308

~i. ,- FELL CO;`IST RUCTId`� C_- �I
.� �Resonr;xs-pivision of�5'ate i(,?uaht�,
c."r Q ent of Environment and23atura' / y
= � r � Carolina DfsParttn ! .
� a WELL COI�T1 CTOR CERTIFICATION# j•
• g, WAT R ZONES(de th): I Top Bottosn�---
Top_ Bottom Bottom____ �-
1. YELL CONTRACTORt: Bottom__ — Topr-----
T2 P. DAVZS Top_��-- Toper Bottom_____
Name Top_- ——Bottom_ --
VJell Contractor(Individual) Thickness!
DAVIS BORING Weight Material
an Name Diameter 1.5 Cement
Wall Contractor Company 7. CASING: Depth ry ` — :�
S 481 LARRY ➢ANTS ROAD Top __I—Bottom_91 FL 1 -
Street Address C�C, Top�_Bottom__
LAW►DALE NC ,Ft.__r.
State Zip Code Top ��Bottorn
sClty or Town Material MethodO� 276-344 a. GROUT: Depth Concrete Truce_
Area coda Phone number r/� Top U Bottom _Z0 Ft...._______.--
��"� `Bottom _ —Ft______
2.WELL INFORMATION: r Tops_
WELL CONSTRUCTION PERMIT Top
Bottom Ft._-- "_`_'—
OTHER ASSOCIATED PERMIT#(if applicabbo) r y SCREEN: Depth Diameter Slot Size Material
SITE WELL ID Cif applicable) Ft.�� in, � in. --
Top Bottom
r; Applicable Box}: Residential Water Supply�^p" J Bottom Ft; in. In,
3,WELL USE(Check Top ,
DATE DRILLED Top Bottom Ft in. in.
TIME COMPLETED r f as AM❑ PMEf'
to.SANDIGRAVEL PACK: Sige Material •
Depth
4.WELL OCATION: To Bottom Ft 7 -('� Cr-- _
CO N
Ci®T-c: --�— r Bottom Ft.
q t i� 1 L=�-=i. Top _
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,zp Coda) Top_
Bottom Ft.
TOPOGRAPHIC!LAN ING: (check appropriate box) 11.DRILLING LOG •
0Slope 0Vailey at f GRidge/0Other
Top Bottom Formation Description
LATITUDE _.°G.('. 1/ ( "DMS OR 3X.X/0000 xX DO _/
OR 7X.XXXXXXXXX DO —/._ (_�. �,.f. r..
LONGITUDE: DMS /
Latitude/longitude of
source: S Qfopographic map / i
(location of well must be shown on a USGS tope map andatfached to I ` 1►
this foam if not using GPS) /
5.W LLOWNER ' ' !} �► j/L - f;teai
Gmd d.�a= "--
wner Name 1 j •,
' Ct1 f
Street A dress / Q /
City or Town State Zip Code ^_rl�,�____
Imo_ .
.
Areacode Phone number 12. REMARKS:
6.WELL DETAILS: jl
a. TOTAL DEPTH: 4
I
b. DOES WELL REPLACE EXISTING WELL? YES NO I DO HEREBY CERTIFY Ti if T'THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: �- STANDARDS,AND THAT A:COPY OF THIS RECORD HAS BEEN
(Use'+-if Above Top of Casing) PRONTO TO THE WELL OWNER. a
d. TOP OF CASING IS _�,fi• ( _FT.Above Land Surface` i �+¢
'Top of casing terminated at/or below land surface may require
•a variance in accordance with 15A NCAC 2C.0118. Sl NATU F CERTIFIEDELL CONTRACTOR DATE
e. YIELD(gpm):
METHOD OF TEST TONY R DAVIS I
f. DISINFECTION:Type Amount 02+ PRINTED NAME OF PERSON,CONSTRUCTING THE WELL
Submit within 30 days of completion to:Division of Water Quality• information Processing, Form GW-1a
Rev.2/09
1617 Mali Service Center,Raleigh, NC 27 6 9 9-1 61,Phone:[phone]