GW1-2021-00232_Well Construction - GW1_20211213

r'�°`SnTt'a•` '
s I RRUDENTIA_L WELL CONSTRUCTION RECORD
North Carolina Departurent ofEnvisanment and Natural Resources-Division of Water Quality
�'. WELL CONTRACTOR CERTM CATION# (.le_7
1.WELL CONTRACTOR: g. WATER ZONES(de
TONY R DAVIS Top__ Bot= Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Wel;Contractor Company Name
Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
StreeiAddress To Bottom FtJ 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
Clty or Town State Zip Code
L 704) 275-3434 r Top Botiom Ft
Area code Phone number 8. GROUT: Depth Material . Method
2.'WELL INFORMATION: / Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# tl �T Top Bottom Ft.�
OTHER ASSOCIATED PER MT#(ifapp:icstle). Top Bottom Ft.
SITE WELL IQ#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box):, Re:sidentlel Water Supply* Top Bottom Ft.1 in.. in.
DATE DRILLED Top Bottom Ft. in. in.
TIME COMPLETED_ AM� PMC;-- Top Bottom Ft: in. in-
TIME
WELL LOCATION: 10.SANDIGRAVELPACK-
Depth -size Materiel
CITY: l�+wa/M•` ® 11 COUNTY J Aicdco
Top _Bottomr.& Ft. 78—M Gravel .
L o o&U k, '`Go?� Top _Bottom Ft.
(Street Name,Numbers,Coffieurifty,SubeWision,Lot No.,Parcel, 4 Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (che:k apprapdoe box)
pSiope E)Valley alSkeE]Ridge 00ther 11.DRILLING LOG
'Top Bottom Formation Dikription-,
LATITUDE .'"DMS OR t?XX XXX)OOOC DD
4
LONGITUDE "LDMS OR 7X DD
Latitudetiongitude source: RORGoI OTopographic map / ^^
(loc#fon'of well must be shown on a USES topo mao andettached to,
this formifnot using GPS) 1 P ;rig 5,..{' .':'UIc-i1
5.WELL OWNER
Owner Name
� G /
treet dress
'U1//c / /
Cry or Town State Zip Code /
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O N040+-"
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: _I' FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Too of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER,
d, TOP OF CASING IS FT.Above Land Surface
'Top of casing
terminated at/or below land surface ma re uire
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OXIFERTIFIED WELL CONTRACTOR DATE
e, YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type Amou 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,NC 27699.161,Phone:(Big) 807-6300 Rev.2/09