GW1--04131_Well Construction - GW1_20230623

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' * c _ ESIDEI4 TIAL WELL CONSTRUCTION RECORD'
a L y� North Carolina Department of Environment and Natural Resources-Division of Water�Qua!ity
WELL CONTRACTOR CERTIFICATION# 2 �-..J 6 - J' 1
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1.WELL
LL CONTRACTOR: •
_TONY R DAVIS g• ZONES(de th:
Top_1- Bottom Top _Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name -
1481 LARRY DAVIS ROAD Thickness/
7. CASING: Depth Diameter Weight Material
Street Address Top 74l Bottom Fi._ 4 .
5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code --
( 704 j 276--3434 Top Bottom Ft._
Area code Phone number - S. GROUT: Depth Material Method
2.WELL INFORMATION: Top Bottom 20 FL Concrete Truck
WELL CONSTRUCTION PERMITS Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.�
SITE WELL ID#(1 applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ge•""/ Top Bottom Ft.__`in. in.
DATE DRILLED.....5—,26- .2_3 Top Bottom Ft. in. in.
TIME COMPLETED /3 .' 0 CoAM 0 PM _... Top Bottom Ft. in. in,
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
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Jp� /� Depth -Size Material
CITY: 'OUNTY� -t,,( �/_� Top2v Bottom '� Ft.,78=H Gravel
r' Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,;ol No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/ D SETTING: (check appropriate box)
DSlope pValley Flat ❑Ridge _Cher 11.DRILLING LOG
•Top Bottom Formation Description
LATITUDE : VDMS OR EX.XXXXXXXXX DC /
LONGITUDE 43"DMS OR 7X.XXX XX)OCX OD /
Latitude/longitude source: PS Oi opographic map /
(location of well must be shown on a USGS topo map andattached to / �_
this fomn if not using GPS) / E'y r _,a r 3.ti r; C
5.WELL OWNER / ° �'' `
.U.10eN.R..T Lk-Sr LC / MIN 2023 .
.OAwneer Name // ,', -.o. /
4.) s7 LL,D (f !G. • / Info;ma'DW ii-.5 GArg Ursa
Street Address
City or Town State Zip Code ' /
Area code Phone number
6.WELL DETAILS: ,.i
12. REMARKS:
a. TOTAL DEPTH: (/ / C�
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ..S if FT. ACCORDANCE WITH 15A.NCAC 2C,WELL CONSTRUCTION
(Use"+°if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
I PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS ( FT.Above Land Surface*
°Top of casing termina ed at/or below land surface may require • ( 4 f - _
a variance in accordance with 15A NCAC 2C.Oi i$, Sly:ATURE 0 RTIFI WELL CONTRACTOR -�T
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Type mount /6 O . PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1517 Mail Service Center, Raleigh, NC 27599-161,Phone : [phone] '° ' 'U`''z
Rev.;JCS