GW1-2021-05992_Well Construction - GW1_20211008

RL IDENTIAL WELL CONSTRUCTION RECORD
r r North Carolina Deparment of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION
I.WELL CONTRACTOR: g. WATER ZONES(dap
TONY R DAVIS Tope Bottom Top Bottom Well Contractor(individual)Name
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name ToP Bottom TOP Bottom
1481 LAM DAVIS ROAD Thickness/
Street Address 7. CASING Depth ;Diameter Weight Material
LAWNDALE NC 28090 Top Bottorll�Ft.! 24 1.5 Cement
City or Town ToP Bottom Ft!
State Zip Code —
( 704) 276-3434 Tap Bottom Ft.
Area code Phone number S. GROUT: Depth Material
2.WELL INF6RMATiON: Q Method
Top Bottom . 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# ' : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicabe) Top Bottom Ft--
SITE WELL ID#(rf applicable)
9, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply jer..'o, Top Bottom Ft. .In, in,
DATE DRILLED Top Bottom Ft. in. in,
TIME COMPLETED • AM 0 PM g6ww— Top Bottom - Ft,l in. in,
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
CITY: '�,�'�-�,,,,,���,, '�,��.�,, ,� '� d, Depth size Material
l w�• G � J�[lla cou/NTY ` roP.�Botto `Ft. 7$=M Graver
Top . - Bottom Ft.
(Stnret ame, umbers,Commundy,Subt0slon,Lot No.,Parcel,Zip Code)
Top-- Bottom
TOPOGRAPHIC 1 LAND Ft;
S ppp ox)
❑Slope []Valley Bf1 ❑Ridge p0ther 11.DRILLING LOG
LAML;6Fy,�+' '..Jswb DMS OR 3X.)o0oU0M DD Top / Bottom Formation Description
LONGITUDE •: DMS OR 7:<.)ooDOopcXX DD J i -
Laftdallongitude source: Oft- Dropographic map /
(location of well must be shown on a USG S topo map andattached to I
this form if not using GPS) rn
/
S.WEL209
L OWNER
ilmetAddress
er Name -V�,!!,iZI N� sing Unit
/ l lOf1
City or Town
State Zr /
Area code Phone number /
S.WELL DETAILS: 12. .REMARKS:'
a, TOTAL DEPTH: V
b. DOES WELL REPLACE EXISTING WELL? YES 13 NO
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 THATA COPY OF THIS RECORD HAS BEEN'
d. TOP OF CASING IS "' PROVIDED TO E WELL OWNER'
FT.Above La:id Surface• -
•Top.of casing terminated at/or below land surfer:may require
a variance in accordance with 15A NCAC 2C.01 IS. '
SIG TURE O FI W(LC CTOR DA
e. YIELD'(gpm): F rest= TONY R DAVIS
f. DISINFECTION:�Typ�j�o
•Amount
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days Of completion to: Division of Water Quality• Inforrnatlon Processing,
1617 Mail Service Center,Raleigh,NC 27699-161,Phone :[phone] Form GW-ia
Rev,2/09