GW1-2022-08769_Well Construction - GW1_20220909

4
.RE'S1'DEi'yT L WELL CONSTRUCTION RECORD
? NoAh Carol.na Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9
1.WELL CONTRACTOR: g. WATU ZONES(dept
TONY R DAVIS Top Bottom Top Bottom
Well Contractor(individual)Name Top BotIom� � Top Bottom
DAVIS WELL BODGING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7, CAS N Depth Diameter Weight Material
Street Address Top Bottom4 Ft. 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code
( 704_ 276-3434 Top Bottom Ft.
Anna code Phone number S. GROUT: Depth Material Method
2.WELL INFORMATION: Top' 0 sottom 20 Ft, Concrete Truck
9,34
WELL CONSTRUCTION PERMIT# Top_ Bottom FL
OTHER ASSOCIATED PERMIT#(ifappiicable) Top Bottom Ft,
SITE WELL la#(If applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Ap cable Box): Residential Water Supply p Top Bottom Ft, -in. in.
DATE DRILLED !) /G,., Top 8nttom Ft.i in. in.
Top Bottom Ft,' in. in.
TIME COMPLETED �('� _ AM❑ PM 91`0�
4.WELL LOCATIO : �G 1 10.SANDIGRAVEL PACK:
CITY: d COON LAii41�1['rep th Size Material
Top ottom Ft. :�/8—M Gravel
pTop sottom FL
(Street Name,Numbers,Community,SubdivAbn,Lot No., arcel,Zip Code) Top Bottom Ft:
TOPOGRAPHIC 1 'L�0.N�TING: (check appropriate box)
❑Slope DValley Flat pRidge pother 11. DRILLING LOG
Top Bottom Formation Description
LATfrUDE "DMS OR 3X.XXXXX)0=DD /
LONGITUDE - "DMS OR 7X.XYJCXXXXXX DID
Latitude/longitude source: ❑GPS &wrOg6phic map / "� _°'
(location of well.must be shown on a USGS topo map andattached to
this form if not using GPS) /
S.WEL OWNER-14f, 11I0V,0 0 A?a
/ .!
Owner Name SRI
'Add s -
ity or Town $late Zip Code /
U /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH•
b. DOES WELL REPLACE EXISTING WELL? YES NO❑
i DO HEREBY CERTIFY THAT T!iIS'JVELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:� _FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above To of Casing) STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED E WELL OWNER.
d. TOP OF CASING is FT.Above Land Surface-
'Top of casing terminated at/or below land surface may require'
a variance in accordance with iSA NCAC 2C.C116. SIGPfATUREI5F CEIMFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type mount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW_1a
1617 Mall Service Center, Raleigh, NC 27699-161,Phone:(919)$07-6300 Rev.2.109

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