GW1--05101_Well Construction - GW1_20230804

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frg/fqr T, i ,• �f. RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
`��.....," WELL CONTRACTOR CERTIFICATION# 65(9 `i
?.WELL CONTRACTOR: g. WAla ZONES(depth':
TONY R DAVIS Top / Bottom . ej 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. CASIjJG� Depth �� Diameter Weight Material
Street Address • Top "/ Bottom Ft. 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code
( 704) 276-3434 Top Bottom Ft,
Area code Phone number 8. GROUT; Depth Material Method
2.WELL INFORMATION: 0 �+.2 Z,./I et A2 Top 0 Bottom 20 Ft Concrete Truck
al WELL CONSTRUCTION PERMI r[i�I I Top Bottom Ft,
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
•
SITE WELL ID#(d applcabie) . ' 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applica le Box): Residential Water Supply 001"*....°e Top Bottom Ft, .In. in.
DATE DRILLED Top Bottom Ft, in. in,
TIME COMPLETED . •
• — AM ID pM ,,.o/ Top Bottom Ft in. in.
4.WEL TIO 10.SAND/GRAVEL PACK:
,// Depth -Size Material •
CITY: G COUN. klb Top 24a Bottom 4 � . 78—M Gravel
74/ i,J y aO / TOPBottom Ft.
(street Name,Numbers.Comm ity, ubdivision, No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTIN check appropriate box)
OSlope CValley OFlat dge ❑Other 11. DRILLING LOG •
•Top Bottom Formation Description
LATITUDE p� DMS OR 3x.XXY.)Cooccx DD / a�..� ,,,clio#23P
LONGITUDE.. f _ F DMS OR 7X.XX)OCXXYJUC DD / ° "`"'Ida. f
Latitude/longitudesource: C- Qropographicmap / /l�G C/
(location of well must be shown on a USGS topo map andatlached to /
this form if not using GPS) 1 {fit-„,,.1,;.,., :3,
W ELL WNER �,,/ G�j�' / rithi' 7,0,-0.
caner N'rogi 1 -- _
/6�eame0 ir' . x me)
ifilletAdd74) ,\ its3 c
City or Town State Zip Code ' /
( ) / '
Area code Phone number
12. REMARKS:
6.WELL DETAILS: 41 .
a. TOTAL DEPTH: •
h. DOES WELL REPLACE EXISTING WELL? YES NO 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing / FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•if Abov T p of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
Q( PROVI. D TO THE WELL OWNER.
d. TOP OF CASING IS 1 Fr.Above Land Surface` • (")
`Top of casing terminated at/or below land surface may require l i cial ie ��� 23
a variance in acco ance with 15A NCAC 2C.0118. 4 �JJ
GNAT •F CERTIFIED �ELL CONTRACTOR DATE
a, YIELD{gpm): METIV OF TEST TONY R DAVIS •
m
f. DISINFECTION:Type tZ,Aount t rii az PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to; Division of Water Quality• Information Processing, F ,
1617 Mail Service Center, Raielgh, NC'37699-161,Phone:(919)S07-6300 om Gb9 1a
Rev.2/09