GW1-2021-01864_Well Construction - GW1_20210503

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REsrDENTW 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):
TONY R DAVIS Top- Bottom,��� Tap Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness)
1491 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top B0ttom­'--1-Fj-447Ft. 24 1.5 Cement
LAWNDALE NC 28090 ; Top Bottom Ft
City or Town State Zip Code Top Bottom Ft.
t 704 276-3434
Area code Phone number 8. GROOUT: Depth Material Method
z.WELL INFORMATION: Top Bottom 2O Ft Concrete Truck
WELL CONSTRUCTION PERMIT# r �( Top Bottom Ft
OTHER ASSOCIATED PERMIT#(Ifapoiwble)
Top Bottom Ft
SITE WELL ID#(rf applicable) 9. SCREEN: Depth Diameter Slot S!ze Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft ln. In.
Top Bottom Ft. in. in.
DATE DRILLED " NEW Top Bottom Ft. in. in.
TIME COMPLETED'
10.SANDIGRAVEL PACK:
4.WELL LOCATION: Depth $[ze Material
CITY: COUNTY Top _Bottom 4VIOFt 78—M Gravel
As Top Boftorh Ft.'
(Street Name,Ndmbers,Comm `SubdN ision,Lot No.,PmuW-Zip Code '�'. Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING (check appropriate box) 1.DRILLING LOG
OSlope DValley Qpat'�0111dge OOther 'Top Bottom Formation Description
LATITUDE ' DMS OR 3X.XXXXXXXXX DD /
LONGITUDE �°DMS OR 7X.XX)OC)WCXX DD
Latlhrdehongitude source: ZiU Qropographic map
(location of wall must be shown on a USGS topo map andattacned to /
this form if not using GPS)
S.WELL OWNS
c ra
�
Owner Name
S tAddrE ^ / ,1�gr.�it 91)illt
Li
City or Town State Zip Code /
Area code Phone number 12, REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 1 SA NCAC 2C,WELL CONSTRUCTION
(Use°+'ff Above Top of Casing) STANDARDS,AND THAT A COPYOF THIS RECORD HAS BEEN
PROVIDED IF THE WELL OWNER.
d. TOP OF CASING IS ` FT.Above Land Surface" �..� �
'Top of casing terminated allot below land surface may_requlre • l
a variance in accordance with 16A NCAC 2C.0118. 71NATURSWIsr-ERTIFIEDWE ONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:T Q Amount d PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
Ie17 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09