HomeMy WebLinkAboutWELL-02-2022-166272.TIF 1
`� I RESIDENTL4L WELL CO�STRCtC7t0`(RECORD
` . North Caroliom Dtpartrncrit of Ervaormcnt and Natural R.eso'rces-Division
on of-Water Quality
-- WELL CONTRACTOR CERTIFICATION t* 2 6 (4 -
1.WELL CONTRACTOR:
T'ONY R DAVIS g. WATER ZONES(depth:
Weil Contactor(Individual)Narna _ Tcp ) Bottom Top Bottom
Top Bottom Top Bottom
DAVIS WELL BORING
Top &ton Top Bottom Well Contractor Company Name
1481 LARRY DAVIS ROAD Thickness/
7. CASI C: Depth Diameter Weight Material
Stree:Address 24 1.5 Cement
Top ! Bottorr Ft-
LATene LE NC 28094 Top Bottom FL
City or Town Stan Zip Code .
c 7041 276-3434 Top Bottom Ft
Arse code Phone numSer a. GROUT: Depth MatertaJ Melho?
2.WELL INFORMATION: r// Top 4 Bogom 20 Ft- Concrete Truck
WELL CONSTRUCTION PERMITS 02420 2 2 �Jt4 Top Bottom Ft.
OTHER ASSOCIATED PERMIT**ecoomiaie) Top Bottom Ft
SITE WELL IDAr,Neppbcatre) 9. SCREEN: Depth Diameter Slot Size Mareriii
3.WELL USE(Check Applicable Box): Residental Water Supply 1:00/°_ Top Bottom Ft .1n, in.
DATE DRILLED ,
Top Borcm FL in. in.
Pam" . Top Bottom Ft in, N.
TIME COMPLETED Q AM 0 P
4.WELL LO A:O - 10.SAND/GRA— L PACK:'
. r / ' /� IIepth- titre Material
CITY: !!! 111 e r�, ycQoua / 4 Top 0 Bottom ee AL i 8—M Grave 1
2.
O [T�7 v LrLS Top_ Bottom P..."- :/---
Name,Nurnberg,Communry,$ubd'tvftlan,Lot No,,Parcrl,Zip code) Top Bottom Ft.
TOPOGRAPHIC/LAND S NG: (rh., approprirte boYJ •
pSbpe ❑Valtaly ORidge p Crier _ I 11, DRILLING LOG
'Top Bottom Formation Deecrtption
LATITUDE :: ,' "DMS OR 3x.roccxx)c.tx DD /
LCNGITUDE .". ' -DM5 DR 7x.xxxxxXxXx DD /
t Latitude/longitude sourr e: CGPS aeirtTgrephic map /
/
rlocaDen of well mbst be shown on a USGS tope map andatteched to
this form,1 not using GPS) / _
!
5. LO HER
/
Owner Name I
, 29 .7.. 6•-"r..‘ CgcAisc -cr- ..
c reef Adams _---_ /
C`ty or Town State Zip Coda /
L —� /
r—
Area code Phone number 12, REMARKS:
g,WELL DETAILS: f
a. TOTAL DEPTH: (�
p, DOES WELL REPLACE EXISTING WELL? YES4 D T DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEC IN
c, WATER LEVEL Below Tap of Casing: al Fi', ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'tt Above o f Casino) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BecN
PROVIDED TO THE WELL.OWNER.
d. Top OF CASING IS- FT.Above Land mSay
Q) z_4
++Top o`casino terminated aWor below land surtace may require y 7 f�T R.
a variance In accordance with 15A NCAC 2...0119, SIG ATURE OF _ l IFIED WE-I.CONTRACTOR CATE
EDD ti F TEST TONY R DAVIS
e. YIELD(gpml ri
t, DISINFECTION:Type to f 4mount I6 . PRINTED NAME OF PERSON CONSTRUCTING THE WELL
otf completion to: Division of Water Quality - Infermat'on Processing, po, ;�ti,_.s
Submit within 30 days
1 617 Mail Service Center, Rafei ,,gh, NC 27699-161. Phone:(919)807-6300 Rev ;rC?