GW1-2021-02545_Well Construction - GW1_20210805

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RM IDENT1AL WELL CONSTRUCTION RECORD
North Carolina Deparl went of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WALER ZONES(dep ):
TONY R DAVIS TO Bottom Top Bottom
Well Contractor(individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Welt Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASING: Depth iDiameter .Wei ht Material
StreetAddnsss TO �aothrn.. tj 24 1.5 Cement
LAWI�DALE NC 28090 Top Bottom FtL
City or Town State Zip Code Top Bottom Ft
t 704 276-3434
Area code Phone number 8. GRQUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft, Concrete Truck
WELL CONSTRUCTION PERMIT# " Top Bottom Ft
OTHER ASSOCIATED PERMIT#(i applicable), Top Bottom Ft
SITE WELL ID#(If appGeatile) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ : Top Bottom Ft. .in; in.
DATE DRILLED • Top Bottom FL In. in.
TIME COMPLETED AM 0 PM I.r : Top Bottom Ft' In. In.
4.WELL LOCA'n : 10,SANDIGRAVEL PACK:
^' Depth Size Material
CITY: , oUNTY Top�U Bottoma-3_7Ft. '18—M Gravel
L j�jA^. tom)/L,cQ 8 : Top Bottom Ft
(Sired Name,Numbers.Community,Subdivision,Lot No. aced,Zip C ) Top Bottom Ft. "
TOPOGRAPHIC/LAND SETTING: (check appmprleta box)
OSIDpe oValley >TIet�oRidge 001her 11.DRILLING LOG
LATrIUDE ��(�MS OR�X.)t7000fX)CX)t DO
Top Bottom Formation Description
. _�lr.�s.T� /
LONGITUDE W'Na� R y IuIS OR 7X-V000010=DD /
Latitude/Iongitude source: 615I& [1r0pogrsphl0 1nep /
(locaffon of well must be shown on a USG'S topo me,)andaftached to l
this form if not using GPS)
S.WELL N
Owner Name ,,ww / r
tAdd s
City or Town Stet a Zip Code /
Area code Phone number
12. REMARKS:
8.WELL DETAILS: -
a. TOTAL DEPTH,•
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 43 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+-if Above Top of Casing) STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL OWNER.
d. TOP OF CASING IS*natadlor
�,Above Lind Surface•:.'Top ri casing ter below land 2C.0 Ie may require I V�i
a variance in accordance with 15A NCAC 2C.0 1 t8. SIGNATURE E TIFIED ELL CONTRACTOR
e. YIELD(gpm): _METHOD of TEST TONY k DAVIS
f. DISINFECTION:Type Amounts PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Div ision of Water Quality- information Processing,
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone]
Form GW-1 a
Rev.2/09.