GW1-2022-01295_Well Construction - GW1_20220112

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RESIDENTIAL WELL CONSTRUCTION RECORD
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s y r North Caroli:ia Departnient of Environment and lNatural Resowc:s-?3ivision o V4 titer Qcality
WELL CONTRAC'I'OR CERTIFICATION#
1.WELL CONTRACTOR: — g..�BTU ZONES(depth))'�-'
TONY R DAVIS Top'. Botio,n �t�� Top E3of om
Well Contractor(individual)Name Top .-Bottom ' Top _-Boaom
DAVIS WELL BORING Top— Bottom Top Bottom
Well Cont Tractor Company Name
Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth �'�' Diameter Weight Material
Street Address — Top Botto;,$ 1Ft 24 1.5 Cement
L AWND ALE NC _28090
Top Bottom Ft. t
City or Town State Zip Code
704; 276-3434 = Top Bottom Ft._
Area code Phone number B. GROUT: Depth' Material Method
2.WELL INFORMATION- / Top;'- 0 Bottom 20 Ft. Conic ete Truck"
WELL CONSTRUCTION PERMIT 1 o � + Top Bottom Ft.
OTHER ASSOCIATED PERMET#(if applicable) ToP Bottom Ft.
SITE WELL ID#(if apprcab;e) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Appiicable Box): Residential Water Supply, ''� Top Bottom Ft. in. in.
�i Top Bottom Ft. in. in.
DATE DRILLED ., -
Top Bottom,,,•- Ft. in. in.
TIME CONA.PLETED AM p P1
4.WELL L CATICN: 10 SANDIGRA.VEL PACK:
f apt 81ze Material
CITY:_ Cc,UNTY �+/ To Bottor t
' ' P
1?op Bottom Ft'
(SVeet N me,Numbs ,Commu7rty,PubdiAiion,Lot No.,pares),Zp Codel op_ 3ottom Ft.
TOPOGRAPHIC/L, tND'SETTING.`(chec,k apPmprlate box)
pSlopn OVaileY:, pRtdge. pOther 11 DRILLING LCG
Top Eottom Formation Descnpton
LATITUDE - " �A1S OR 3X.XXXXX)O=DD
1: -
LONvfTUDc'- pMS OR 7X.XX)0OCXXXX DD
Latibudeflongitude source: []Topographic map —
(loca"on of well must be shown on a USG'3 topo map andattached to
this form i.'nct using GPS) h i
5.WELLOWNER /-- — —
M
Owner Name
y.
S eet.Add ess — -
tj 2G
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6,WELL DETAILS:
a,.TOTAL DEPTH
b. DCES WALL REPLACE EXtST1NG WELL? YES❑ NOfar-" I DO HEREBY,CERTIFY THAT THIS WELL WAS`COttiSTRUCTED iN
c. WATER'LEVEL Belovr.Top of Casing �, ACCORDANCE V'•r'ITH 15A NCAC 2C,WELL CCNSTRUCTION
{lse +.r{ above op of,Gast sg) STANDARDS.AND THAT A,:OPY OF THIS.REC.ORD.HAS.BEEN
PROVIDED TO THE WELL OWNER.
%0. TOP 0`12 CASING IS FT:Abcve Land Surface'. l
!Top of casino terrain ed at/orbelow land surFece may require ._- (�►.. '� r
a variance in accordance with 15A NCAC 26 sOt18.,. : IGNATUR CERTIFIED W-LL'CONTRAGTOR DATE
e. YIcLQ(gpm)`. METHOD OF TEST "TONY R DAI IS
YP f
If, DISINFECTION:T Amount PRINTED NAME OF PERSON CONS i RUCTiNG THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form, Gw-ta
1617 Mail Service Center,Raleigh, NC'27699-161,Phone:[phone] Rev.