GW1-2022-08599_Well Construction - GW1_20220513

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carol sia Department of Environment and Natural Resources Division of`Hater Quality
WELL CONTRACTOR CERTIFICATION# t
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Tope- Bottom Top Bottom
WeG Contractor(individual)Name Top Bottom Top Bottom
DAVIS WELL BORING = Top Bottom Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address TO Bottom�t.f 24 1.5 Cement
LAWN-DALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft._
�704 276-3434 _
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: j � Top O Bottom 20 Ft Concrete Truck
WELL CONSTRUCTION PERMIT# ! ~ ��! Top Bottom r Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check App stable Box): Residential Water Supply q� Top Bottom Ft,' In. in.
DATE DRILLED J • VZ Top Bottom Ft.. in. in.
} : Top Bottom Ft.' In, In.
TIME COMPLETED / -� AM 0 PM
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
Depth Size Material
CITY Sr e U /�e:OUNTY i Top Bottorr-- F#. ?S"r1 Gravel
. t.Top Bottom F
(Street ame, umbers,Community,Subdrnston,Loi No.,?erceJ,Zip Code) Top Bottom Ft.
TOPOGRAPHIC I LAND S INU: (chezc appropriate box)
❑Slope ❑Valley ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE - _. G' °DMS OR 3X.XXXXXXXXX DID /
LONGITUDE •�jAA DMS OR 7X.XXXXXXXXX DD : J
Latitudellongitude source: aw-e Clropographic map
{location of well must be shown on a USGS`opo map andeffached to 1�
this`arm if not using GPS) J
5.WELL OWNER
1/�► `Y / PfoC ►9
er Name < / pytojeou
Street Address J
Cu tat7�tV v >� C :? D 2! l
City or Town State Zip Code J
Area code Phone number 12. REMARKS:
6.WELL DETAILS: J
a. TOTAL DEPTH:_r' �
b. DOES WELL REPLACE EXISTING YdELL? YES p N0 I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: Z5 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+°rf Above Top of Casing} STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN
�. , PROVIDED I THE WELL OWNER.
d. TOP p CASING ie Ff.Above Land Surface` 5 I .~
'Top of casing ternina d atlor below land surface may require �/
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OFICIRTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): _METHOD Of TESTTONY R DAVIS
f. DISINFECTION:Type /&runt PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Procesis3ng, Form GW-Ia
1617 Mail Service Center,Raleigh,NC 27699.16i,Phone:[phone] Rev.2109