GW1--00526_Well Construction - GW1_20240118

1.:?�ir-1y� �� D
Ile ,..s'i RESIDENTIAL WELL CONSTRUCTION RECORD
' ' : North Carolina Department of Environment and Natural Resources-Division of Water Quality.
W .. .e.fi WELL CONTRACTOR CERTIFICATION# 2 Co-15(
•
1.WELL.CONTRACTOR: g. TER ZONES(de th):
TONY R DAVIS Top I Bottom L Top Bottom
Well Contractor(Individual)Name Top Bottom I Top Bottom
DAVIS WELL BORING Top Bottom ! Top Bottom
Weil Contractor Company Name
• 1481 LARRY DAVIS ROAD I Thickness!
7. ASING: Depth _ ® Diameter Weight Material
Street Address / j, 5 24 1.5 Cement
Top1 Bottom, Ft.
LAWNDALE 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: Q Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#22 ®-Jd a Top Bottom Ft.
OTHER ASSOCIATED PERIv11T#01 applicable) Top Bottom Ft.
I . •
SITE WELL ID*Cif applicable) • • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Bo ): Residential Water Supply C'�� Top Bottom Ft. ' .in, ' In.
DATE DRILLED i 1/.J\ ' • 2, Top Bottom Ft. I in. in.
TIME COMPLETED I.3 d 0 AM❑ PM l Top Bottom Ft. k; . In, in.
10.SAND/GRAVEL PACK: I
d.WELL LOCATION: q / Depth I Size Material
CITY: 1,.,.1��L+�J �. 1��, f �c/ouNerTY4//� �0n6� Top IV Bottom Ft.' '78—M Gravel-
�7_7 i •W i d.��rl Awe/ s�60'$ Top Bottom FL I. ,
( treet Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom FL.
TOPOGRAPHIC/LAND SETTING:(check appropriate box) •
❑Slope CiValiey at DRidge °Other 11. DRILLING LOG
,
LATITUDE_•' '„ G"DMS OR 3X.XXXXXXXXX DD J-
Bottom Formation Description
$1 _LONGITUDE • G Top •
UP°DMS OR TX.Xxxxxxxxx DD ---- r+•.----•- A'VT.
I Latitude/longitude source: [g'PS ❑topographic map / L. _ r, ) •
(location of well must be shown on a USGS topo map andatfached to '
this form if not using GPS) / ! , J Al 1 S [024
S.WELL OWNER t . �,/ � G( /
- aJ k b' �J�+b'
:,,,::,,:a lis t
/ J'
O rName / -
Street
ki Qs°g
City or Town • State Zip Code ' /
( ) • / .
Area code Phone number
12. REMARKS: ,
6.WELL DETAILS: k /�
ifv�' ,,,`_,
a. TOTAL DEPTH: - i
b. DOES WELL REPLACE EXISTING WELL? YES CI NO jb-•#
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: .lw/J 4 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d, TOP OF CASING IS 4. t FT.Above Land Surface' ���/ �� /c).
'Top of casing terminated aVor below land surface may require ` lz 0I� g 43
a variance in actor ante with 15A NCAC 2C-0118, SI-NATU`F WIF CERTIFIED WELL CONTRACTOR DATE
a. YIELD(gpm): mengoP OF TEST TONY R DAVIS f
f. DISINFECTION:Type I M Amount 1 to D Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-la
1617 Mail Service Center,Raleigh,NC 2769e-161,Phone;(SIB)807-6300 I Rev,2/09