GW1--01600_Well Construction - GW1_20240308

i
jF/°,: f;�.` IlUCT10�Ri COTt1
ry 1= Y4 , ../ SXIy. I�►'T`X�1• WELL C01vST 119. .----.:
:�rrti. ii- f 31
\=.!,;,1 : , �1cy North Carolina Department of Environment and`natural Resources-Division of Waller Qua:ity
i.z.j":"L
-' WELL CONTRACTOR CERTIFICATION#__2___b___5_1.." - ! - --, - 1
g, d TE ZONES(de 'h•
9.WELL CONTRACTOR:TONY R DAVIS Top Bottom Top _Bottom
! Top Bottom
Top _ -.Bottom_ r
Weil Contractor(individual)Name Bottom_____,' Top Bottom
DAVIS WELL BORING -_- Top
Well Contractor Company Name
Thickness/
7. CAS'HG: Depth Diameter Weight Material
- 1481 LARRY DAVIS ROAD Cement
Street Address • Top Bottom�' Ft. 24
1.5
LAw:HDALE NO 2S09a _ Top Ba tom _Ft. I
—City or Town State Zip Code pop Bottom Ft._I_
t 7Qj 276-3434 8.• GROUT: Depth �ateria. Method
area code Phone number To O Bottom 20 Ft. Concrete Truck 2.WELL INFORMATION: p rl � �j� !��"'� p
7 "�a tea'✓ ��^ y y Top Bottom Ft._
tYELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(Y applicable)
SITE WELL ID#{it applicable) ' ' 'a, SCREEN: Depth Diameter Slot Size Material
Top- Bottom Ff.,-,min. in.3.WELL USE(Check Applicable Box): Residential Water Supply; Top Bottom Ft.,.`in. _-^ •- in.
DATE DRILLED 1 _I Top •B'dttoni Ft. in. in.
TIME COMPLETED I s1r00 AM 0 PM�
�T '
•: � 10.SANCtGR{1VEl.PAGt4.:
4.WELL L CAT1ON: Depot Gibe fJlateriai
nd,?,A"t 1 �c '+1. •78-M Gravel
CITY: G. C CUNTS��1J/"3 ri► To3ottom
6 5C / NiV 2 �+'J 4 v Top •Bottom. • Ft..
yd-) .Top, Ft..
(Street(Jame;D7u�'nbers •
,Cgmmu�it,Subdivision,Lot No.,Parcel,Za Code) Sio;tofrt' .
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11.r R{CLING LOG
pSlape rJValley pRidge pother Tog - Bottom . • Formation Descriptio- •••
L ATITUDP• !'- "DMS OR 3X.xxxxxXXXX OD t _. • •
/
LON31T1JDy / ". Z S OR/X.XXXXXX(XX DD - -----
Latitude longitude source: ' [Topographic map ZT i' is�
(location of wall must be shown on a USES fopo map andet ached to -I. .. °'�•
' 4��f~ri
this form if not'using GPS) V 'a LU14 7,1") .
S.WELL ER /, - . ! 1►,=,r•��,: _ - . ..
2 e( o ,f 2 y,/Ury , tV,t..) ct • / •_
•
Street ddres. / -
4iti C i"stale5' Zip,/ / . . .
Clty ocTown,.
_• -- -
Area code Phone number 12. REMARKS: "^
5.WELL DETAILS: G� --
a.,TOTAL DEPTH: t�� / "`—"'- --
b.•aOES:WELL REPLACE EXISTING WELL? YrEySJ b.. NO • I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN
"c.'WATER LEVEL Below Top.of Casings 'I FT,': ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use•+'if Above Top of Cashig) STANDARDS,AND THAT A•CPI?Y OF THIS RECORD.HAS.BEEN...
PROVIDED TO THE WELL OWNNER.• ..•d. TOP OF CASING IS d ,FT.Above Land surface Surface" - a _ , r ,�'Top of casing terminated at/or below land face may require 7___7__C4e-LRd : 41
- a variance in accordance with i 5A NCAC 2C.0118. • TUTIFIED I'4'E.L CONTRACTOR.,: DATE,� / TONY R DAVIS
• e. YIELD(gpm):-�p� e�.,LUMETI-ICr1a OF TEST
f/�a Amount I G Z PRINTED NAME OF PERSON CONSTRUCTING THEME'L
E. a1SINFECTION:Typ �
Submit within 30 days of completion to: Diyision of Water Quality- information Procelaing, Form Gov-la
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:(9 i9)807.=6300
Rev.2/Cc