GW1-2021-03492_Well Construction - GW1_20210607

r _y .RES1 DENTZAL WELL CONSTRUCTION RECORD
Borth Carolina Deparlm-nt of Environment and Natural Resources-Division of Water Quality
10
.J 6 ...
WELLWELLCONTRACTORCONTRACTOR CERTIFICATION# �f.L._
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Top _Bottom 01 Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD T. CASING: Depth 1 Diameter Weight Material
Street Address ; Top Bottom A' Ft 24 1.5 Cement
LAWNDALE NC >.8090 Top Bottom Ft,
City or Town Sts.te Zip Code Top Bottom Ft
c 7041 276-3434
Area code Phone number 8. GROOUT: Depth Material Method
2-WELLINFORMATION. / Top Bottom ZO Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# tiQ fl Top Bottom Ft.
OTHER ASSOCIATED PERMrr#(ff applicable) Top Bottom Ft.
SITE WELL ID#(If appArable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Vt ater Supply Ai-d Top Bottom Ft, ln. in.
DATE DRILLS '� �1
Top Bottom Ft! In. In.
+♦ !
TIME COMPLETED / t t!%G AM lit "M❑ Tap Bottom Ft.� (n, in.
4.WELL LOCATION 10.SANDIGRAVEL PACK: !
y • Depth aims Material
cirY: couNTY�/ D Toq,"�(�Bottom-�VIO­Ft: 78-M Gra-vel
(Jy r Top Bottom Ft.
SJ—
(Street Name,Numbers,community,SubtGvislori,Lot No..Parcel,Zip Cod) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (che:*appropde:a box)
[]Slope OValiey 4"411' aRidge ❑other 11. DRILLING LOG
•Top Bottom Formation Description
LATITUD 4-3A* DMS OR'-,,X.XXXXXXXXX DID / W
LONGITUDE . 4M M MS OR(X.XXXXXXXXX DD /
Latitudellongitude source: ;pPr C7ropographic nap
(location 0f well must be shown on a USGS topo ma i andaftached fo
this form if not using GPS) l
S.WELL OW ER /
R--ta-57' /
net Name e
f J4
S Address I / tin
CL"`� �� __ l Irtf3rr.•a . n CorY�On
City or Town Stete Zip Code / � —
U �
Area code Phone number
12, REMARKS:
8.WELL DETAILS:
a. TOTAL.DEPTH: (�
b. DOES WELL REPLACE EXISTING WELL? YE g{jIQ60 I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. : ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO IE WELL OWNER.
d. TOP OF CASING is FT.Above.-and Surface
'Top of casing terminated aUor below land surf ace may_require
a variance in a once with 15A NCAC 2C.011 B. SIGNATURE OF&mRTTFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_ METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type Amou,rt•, 4•?-w PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing; Form GW-1a
1617 Mail Service Center,Raleigh,NO 27699-161,Phone:[phone] Rev.2109