HomeMy WebLinkAboutWELL-06-2022-174695.TIF C 7-xf\ \
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RESIDENTIAL WELL CONSTRUCTION RECORD
;K).�+ { . '- •�i North Carolina Depa~n::rt of Environment and Natural Pesot:: >s-Division of Water
Quaiity
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1.WELL CONTRACTOR: £. WATER ZONES',deoth):
TONY R DAVIS Top ,0C3 Bottom _ _ Top Bottom____
- Wei Contractor(Individual)Name Tcp Bottom•_ Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contracto:Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top j Bottom 11Ft.
24 1.5 Cement
_ LAWNDALE NC 28Q90 Top__ m Botto ---Ft.,
CIty or Town State Zip Code Top Batton Ft.__ —
L',J 27 5-3434
Area code Phone number e. GROUT: Depth Mate^el Method
_op O Bosom 20 a Concrete Truck
2.WELL INFORMATION:WELL CONSTRUCTION PERMIT# 0 6 102 f 7� Qs'
`op Bosom Ft.
--
OTHER ASSOCIATED PERMIT#(r appii�bie,) Top Bottom Ft.
SITE WELL ID#Crf eppllcabie)_ 9. SCREEN: Depth Diameter Slot Size Material
_ —_ _
3.WELL USE(Check;', IiCable Box): Residential _ Bottom Ft. In. in.
al Water Supply
L. Top Bottom Ft in. Ir•,
DATE DRILLED Top Bottom Ft. in. in.
TIME COMPLETED _ AM D PMja--"----. '
10.SAND/GRAVEL PACK;
4 IAELi.., f'"Tt0 r /� /1, Depth Size Material
CITY', ikLi ��couN1ic J7 Top V Bottom t. 7841 Gravel
. / g35 /1 csig ,R.� /LJc JLt 9 Top Baton F"•
—
(Street Name,Numbers,Community.$irbdiv+:ion,Lot No.,Pafr5ei,Xp L.ode) Top Bottom F:• —.
TOPOGRAPHIC:LAND SETTING: (check appropriate box) t 1.DRILLING LOG
;Si:pe ,t11V 11 UFlat CRidge Other Top Bottom Formation Description
LATITUDE • , "D41S OR 3X.XXXXXXXXX OD /
LONGITUDE•.'$.( . DMS OR 7X.XXXXXXXXX DD — -
Latitude/longitude source: S Dropographic map �—
(ivtsfior of well.must be shown on a USES boo map aniatfached to
fnis fora if not using GPS)
5.1NE,t D NERy7) }A a/ fa_y Co!t ao "a H—
Own ameM O L e.7 u /• - —
/%get Address �j ` /„
City or Town State Zip Code /
/
—
Aree code Phone number 12. REMARKS:
6.WELL DETAILS:
-
a. TOTAL DEPTH: til _ - --
b. DOES WELL REPLACE EXISTING WELL? YES r] NO 4"...°.---.- t DC HEREBY BY CERTIFY TH.AT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: t G FT. ACCORDANCE WITH 15A.NCAC 2C.WELL CONSTRUCTION
STANDARDS,AND THAT F.COPY OF THIS RECORD HAS BEEN
{use"+'tt Above Top of using? PROVIDED T^THE WELLOWNER.
d. TOP OF CASING IS "�'7/' FT.Above Lana Su-Face' f '� �J
'Top of casing terminated atlor &ow land Caface may sacra re 7 1. 22
a variance in a ortiance with 15A NCAC 2::.011e. SIGRF,TURCE S RT 3ED VV,_ N.PACT R DATE
e, YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type mount go 0 Z PRINTED NAME OF PERSON CONSTRUCTING THE'/ELL
Submit within 30 days of completion to: Division of Water Quality- information Processing, Fort,OW-IC
1617 Mat! Service Center, Raleigh,NC 27699-161,Phone :(919)8G7.63OD Rev.G�0S