GW1--02213_Well Construction - GW1_20240409

t
,'� .,n'`rig ' •
i�� �E_ES1•DENT' LL CoNSTRIJCTION REC
? '! f c 's
L f i �i`r:i ,�.
y 7• , �' ybDivision of Water Quality
?i r.+••_1.4� ii North Carolina Department of Environment and Natural Resources,.
.. 0w
41
.. .«�. WELL CONTRACTOR CERTIFICATION#—•— �.�'-- �' f
•
T,op WATERg. _Bottom d ).
1.WELL CONTRACTOR: 1 Bottom
TONY R DAVIS 7op
Top _Bottom !;Top Bottom
Well Contractor(Individual)Name Bottom I Top- Bottom •.
DAVIS WELL BORING Top_
�, Thickness!
Well Contractor Company Name Diameter Weight Material
1481 LARRY DAVIS ROAD 7. CASING: Depth I2 e 1 5 Cement
Street Address '"• Top ( Bottom 6 Ft.
LA iDALE NC 28090 _ Top Bottom Ft. 1 'I
City or Town State Zip Code Top Bottom Ft._ I� i
{ 701}) 276-3434 •
S. GROUT: Depth Material Method
Area code Phone number Concrete Truck
Top Bottom 20 Ft,
2.WELL INFORMATION: / �Bottom Ft.
WELL CONSTRUCTION PERMIT# & E� Top
Top Bottom Ft.
OTHER ASSOCIATED PERM1Tfk{if applicable).
SITE WELL ID#(if applicable) ' ' 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. � I .in. in.
3.WELL USE(Check Applicable Box): Residential Water Supply ID Topes_Bottom Ft. :' in. in.
DATE DRILLED Tap Bottom Ft. 1 in, in.
TIME COMPLETED AM Q PN+�3'" J !
113.5ANDJGRA'VEL PACK: !
4.WELL CAT,IOPi: ,�1 Depth ''Side Material •
+
AL/ COUNTY2/M CO4�+ Top 2V Bottom .7( ,Ft. I:78—M Gravel
• Of(�7' T al�� IA rot 4 �o/b Top Bottom_.__Ft._,
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zp Code) Top Bottom•,_._.FLU..----
TOPOGRAPHIC/LAND ki•'flNG: (check.appropriate box) 11.DRILLING LOG
a Slope C1Valley &Mt CR/i�dge 0 Other 'Top Bottom Formation Description
LATrruDE -1#./' • +g 9"DMS OR 3' (XXXXXXXX DO / —
LONGITUDE: 0"LAMS OR 7X.XXXXXXXXX DJ / i `-�''-"',5 r.' b t 3'q r ,?
Latitudefongitude source: IS Qropographlc map r f Q P� �V
(locution of well must be shown on a USGS topo map andettached to I
.�— �_.�_y.-,
this form if not using GPS) / I Info;,,..- .:: n 'D‘•-•-:-
5.WE LOWNER !, fa ��'e" "_ /— G:vi�; �r_1 _
wirer Name /
q 41 i°40,r4Gici do Pli-14
strut?.dss � 141r 1G ----
City or Town State Zip Code /,__,
Area�code Phone number 12. REMARKS: ,
6.WELL DETAILS:
a. TOTAL DEPTH: 5 I - - / '
b. DOES WELL REPLACE EXISTING WELL? YESU NO lY 100 HEREBY CERTIFY THAT THIS'WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCACI2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing tJ F1' STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+"if Aboveop of Casing) PROVIDED TO THE WELL OWNER: ,�/ •
d. TOP OF CASING IS f FT.Above Land Surface` I j r� ,L ' � r
"Top of casing terminated at/or below land surface may require ��J +
a variance In accordance with 15A NCAC 2C.0118. SIG ATURE Or _ TIFIED WEL 'CONTRACTOR DATE
e. YIELD(gpm): MEiH/OD, F`TEST f j TONY R AVIS j
f,
DISINFECTION:TyperS�� '�""cunt / '+ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ng,
Submit within 30 days of completion to:Division of Water Quality- Information Processi Form GW-1aRev.2/09
1617 Mall Service Center,Raleigh,NC 27699.161,Phone: [phone]
1