GW1--03916_Well Construction - GW1_20240705

{ t ; 1. RL1DNTML_YELL CONSTRUCTION RECORD
r' North Carolina Depar rent of Environment and Natural Resources-Division of Water r'Quality
yM �'� WELL CONTRACTOR CERTIFICATION#
` 6R ZONES(wept )'
1.WELL CONTRACTOR: Top { Bottom ep ._ Top Bottom
TONY R DAVIS Bottom Top Bottom
Top_,______
rU+eii Contractor(individual)Name Bottom__ —,op Bottom-_____-__
DAVIS WELD BORING Top —
Thickness/
Well Contractor Company dame 7. C.4 IN Depth D ameter Weight Material
148i LARRY DAVIS ROAD 24 1.� Gernert
Street Address
Top Botto_ Ft. __,_
NG 28090 Top ,Bottom Ft. _ — -----=
City or
or Town State Zip Code Too Bottom Ft._ —
J
L_704,E 276-3434 — Material Method
8. GROUT: Depth Concrete Truck
Area code Phone number Top G_Bottom�C Ft._
2,WELL INFORMATION: i �j Top Bottom Ft.�_
WELL CONSTRUCTION PERMIT#__ - Top Bottom Ft. ----- ----
OTHER ASSOCIATED PERM17#(rc applicable)_____---_ Diameter Slot Size Material
SITE WELL ID Cif applicable) 9. SCREEN: Depth Bottom Ft. _-in. —, In.
Top
3.WELL USE(Che Appll ble Box' Re dentlal Water Supply Top Bottom Ft. in: r in.
DATE DRILLED '6 / Top —Bottom Ft._ _ in.
TIME COMPLETED
AM❑ Ph�/
10.S.ANDIGRAVEL PACK: Size Material
a.WEL LOCATION: Depth
O ® Tope Bottorr S ?Ft._ 78—M _ Gravel
CIT. COON-"Y
To?_ Bottom _ Ft..
treat Name,. um era,C munity,Subdivision.Lot o.,Parcel,Zip Code? TOp 9ottorr. Ft._
TOPOGR4PWC!LAND SNG: (check appropriate box) 11, DRILLING LOG
0 Slope ❑Valley tat Ridge ■Other`____.
Bottom Formation Description
LAT`TUDE XX
"DMS OR 3X. 0 XYJCX
9
XX Top
DD —_—I —
LONGITUDE �' • , " AS D' OR 7X.XXXX?:XYXX CD f—" —
Latitude!langitude source: :a -S Topographic map _
(location of well must be shown on a USGS tope map andatfached to -/ ,
this form if not using GPS) ; L. �iy^---
5. WNER -I-
—;..-- ----------
///��� Y to
fleet ddresa Cr '16V
(r State Zip Code w i
C', or Town _
Area code Phone number 12. REMARKS: �_
6.WELL DETAILS: � -- _ ---
a. TOTAL DEPT � �,/ _
b. DOES WELL REPLACE EXISTING WELL? YES 0 NC'$�' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
_F. ACCORDANCE WITH,5A NCAC 2C,WELL CONSTRUCTION
p WATER (LUse"L Below Top ofofCaCasing: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+"if•Abav Top of Casingl PROVI ED TO THE WELL OWNER.
FT.Above Land Surface' Cii �r+,� 241
d. TOP OF CASING IS � require �'
*Top of casing terminated at/or below land surface nay R
a valance in accordance with 1 aA NC:4C 2C.0118 IGNAT TONY R. DAVISCERTIFIED lt c.LL CONTRACTOR SATE
ETH F TEST_ ��J.
a.
YIELD(gpm): N/mount?: +`y,""." r=itIN-ED NAME OF PERSON CONSTRUCTING 7E✓E WELL
f. DISINFECTION:Type Form GbV-.a
Submit within 30 days of cotr~zletton to: Rivison of Water Quality - infarrt'tat`on processing,
1617 Mail Service Center, Raleigh, NC 27699•161, Phone :(919)837-G300 Rey.2l6 W