GW1-2021-00049_Well Construction - GW1_20211109

RES'1DENTI4L WELL CONSTRICTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
( .1
WELL CONTRACTOR CERTIFICATION#_
1.WELL CONTRACTOR: g. ATER ZONES(depth):
TONY R DAVIS to Bottom (b Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Weil Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom FL 24 1.5 Cement
LAWNDALE NC 28090 '
_
City orTo>,vn State Zlp Coda Top Bottom Ft.
: Top Bottom FL
L 704) 276-3434
Area code Phone number B. GRQUT: Depth Material Method
2.WELL INFORMATION: TO (J BottorrL. 20 Ft—_Concrete Truck
NVELL CONSTRUCTION PERMIT# ✓'� l/ : Top Bottom Ft,
OTHER ASSOCIATED PERMIT#(irapplicable) Top Bottom Ft.
SITE WELL ID*ff appfcabta) S; SCREEN: Depth ;Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Reside tfal Water Supply 7, Top Bottom In.
DATE DRILLED Top Bottom
T1MEiCOBottom—
n, Top; Bottom .. Ft in. 1n
M PLETED AM�/� 0PM�"� .....
4.WELL L CA nON 1Q SANDIGRAVEL 1?ACK
CITY, , �. COUNTY /4 / e Material'
0 +L�L!� Depth ��
To _Bottom Ft. 78-M Gravel
Top Bottom> Ft.
(S ri o ubdiMslon,Lot Na.,Pzvw,Zt Cod•) `Top' Bottom Ft.
TOPOGRAPHIC/LAND SE
1tVG: (chadc appropriate box)
CiSlope oValley EJA19T ❑Ridge pother 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE '� ��« DMS OR :3XJ000CX=_DD
LONGITUDE MS OR i'X.XXXXXXXXX DD
LatitudeAongbde source: ON0110776pographic map )
(location of weli must be shown on a USGS topo map andattached to
this form if not using CPS)
S.WELL WNER
_.13vNev
owner a V
CA7
t Address � R b
�.�� I — rr. VK , r7.r conreectnlr'r rv,
CRy or Town State Tip Code
Area code Phone number v
S.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:
- 64
b. DOES WELL REPLACE EXISTING WELL? YES p NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C.'WATER LEVEL Below Top of Casing: FT. ACCORDANCE W" 15A NCAC;2C,WELL CONSTRUCTION
{Use•+•i€Above Top of CasIn2T STANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN
PROVIDE THE WELL OWNER
d. TOP OF CASINGIS _FT.Above Land Surface`.:
Top;of casing terminated aflor belovd land surface may require L �• �� Z
a vartahce`in accordance with 15A NCAC 2C.t)1 TB. SIGNATURE NATURE TIFI �WE CONTRACTOR ��// DATE
a. YIELD(8pm):' METHOD F TEST TONY R DAVIS
f, DISINFECTION.Type ount No PRINTED NAME OF.PERSON CONSTRUCTING THE WELL .- .
Submit Within 30 days of completion to: Division of Water Quality- Information Processirg, For,OW-1a
1G17 Mail Serviec Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2109