GW1-2021-03489_Well Construction - GW1_20210607

=�L RESIDENTUL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of'1WatarQuality
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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: '� .- . g. WZONES(dep
TONY R DAVIS ; Top Bottom Top Bottom
Well Contractor(individual)Name "® Top Bottom Top Bottom
DAVIS WELL BORING 02� Top Bottom Top Bottom
Well Contractor Company Name juill 1*1 -
1481 LARRY DAVIS ROAD „PSS%nc Ut11t Thickness!
„9 PrGW 7. CASING: Depth Diameter Weight Material
L WNDdALE NC �n�J 280�3�01 �eJnion Top Bottom Ft. 24 1.5 Cement
Top Bottom_Ft.
City or Town State Z!p Code
( 704) 276-3434 Top Bottom Ft.
Area code Phone number 8. GRQUT: Depth Material Method
2.WELL INFORMATION: / Top U Bottom 20 Fi, Concrete Truck
WELL CONSTRUCTION PERMIT# ... (� Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(trappficat9e) Top� Hot(pin Ft.
SITE WELL ID#(Fr applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply: Top Bottom Ft in.
DATE DRILLED Top Bottom Ft. in. In,
TIME COMPLETED _ AM Top Bottom Ft in. In.
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
d Depth 'Size Material
Cl t! L r.ouNTY Top •Bottom Ft. 78—M Gravel
p Top Bottom Ft. :
(Street NEmie.NEimbeii.Coffimurft Subdnr:don,Lot No., a ip Code) Top Bottom Ft. .
TOPOGRAPHIC P AND,OWIING: (check appropriate box)
oSlope gValley 1394t ❑Ridge.tlOther I I DRILLING LOG
'Top 'Bottom Formation Description
LATITUD !.9r74.. DMS OR 3X.V=X)O=DD
�LONGITUD •• -/ v.Y, "DMS OR 7X.XXXXXXXXX DD /
Latitudallangitude source:. [BPS [Ifopographic map /
(location of well must be shown on a USGS tope map andettaohed to
this form if not using GPS) /
S.WE LOWNER /
L /
Owner ame /
Street dress i 1
CityyBrTown —'— State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS: ,
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES I0 q I DO HEREBY"CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c.WATER LEVEL Below top ofCssinp: �, ACCORDANCE WITH 15A NCAG 2C,WELL CONSTRUCTION
(Use"+'if Above Top of slog) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
'A 1PRO IDED TO THE WELL OWNER
d TOP OF CASING 1S ' i-"f.Above Land Surface'*Top.of casing tenn;nated aUor below land surface may_require
a variance in accordenee with ISA NCAC 2C.0116. Sl TURFWtERMFIED VVELI L CONTRACTOR DATE
e. YIELD(gpm):_ _METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type��Mjpunt 16
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- information process!ng,''
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Penn Rev.2/09 e
09