GW1-2021-01000_Well Construction - GW1_20210419

r
i
I,i "6 RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WATER ZONES(depth): Top Bottom
TONY R DAVIS : Tap i—Bottom "
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thicknesst
1481 LARRY DAVIS_ ROAD 7. CASING: Depth lolamater Weight Material
Street Address Top" Bottom Ft' 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft
City or Town State Zip Coda Top Bottom Ft.'
L 704 276-3484
Area code Phone number 8. GROUT: Depth Matinal Method
2.WELL INFORMATION: /f/jyy �} Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#A,--2a -�.3gSGa; Tap Bottom Ft.'
OTHER ASSOCIATED PERMIT#(trappticable) Top Bottom Ft.'
SITE WELL ID#(ii applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable ox): Residential Water Supply Top Bottom Ft. In. in.
DATE DRILLED11 Top Bottom FU in. in.
� JJ Top Bottom Ft.,!._in. _ In.
TIME COMPLETED _ AM�•-'PM p -
10,SANDlGRAVEL PACK
4,WELL L CATIO p be th Size raterial
CITY: cau rY /9 Top _Bottom Ft, 78-M _.Grave3._
�' Top Bottom Ft'
(Street Name.Numbers,Community,Subdivision,Lot No.;Parcel, p Code) TOP Bottom .Ft..'
TOPOGRAPHIC!LANDS ING: (cheek appropriate box)
[]Slope.C3Valley CRidge ❑Other 11.DRILLING LOG
•Top Bottom Formation Description
LATITUDE` ZS DMS OR 3X.XXXXXXXXX DD
LONGITUDE DMS OR 7X.XXXXXXXXX DD J.
Latitude/iongitude source: Ofopographic map
(location of well must be shown or.a USGS topo map ands#ached to J
this form if not using GPS)
D
S.WELL OWNER
Ow nrNeme Intl
Stre iC;CL+3 vC,,
Addre s J �'
I AL G
City or ovrn: State Zip Code
Area code Phone number -
12. REMARKS:
6.WELL DETAILS: C
a. TOTAL DEPTH:--
b. DOES WELL REPLACE EXISTING WELL? YES p No t I DO HEREBY'CERTIFY THATTHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL.Below Top of Casing: FT. ; ACCORDANCE WITH 15A NCAC 2C,VdELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS'RECORD,HAS BEEN
PROVIDED 10 THE WELL OWNER
d. TOP OF CASING is FT.Above Land Surface'
'Top of casing terminated atlor below land surface may.require F �• �'
a variance in accordance with 15A NCAC 2C:0118.', IGNATURL-ME E lFl W CONTRACTOR DATE
e:YIELD(gprn): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Typ Q ��irnount Q Z/ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
SubmltvAthin 30 days of completion to: Division of Water Quality- Information Pr•acessl g, Form GW-1e
1617 Mail Service Center,Raleigh,NC 27699.161,Phone:[phone] Rev,2109