GW1--00527_Well Construction - GW1_20240118

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7L't` st RESIDENT. WELL CONSTRUCTION RECORD
; � North Carolina Deparanent of Environment and Natural Resources-Division of Water Quality •
N``'"„r WELL CONTRACTOR CERTIFICATION# 2.6_5 ' I
,04
1.WELL CONTRACTOR: g. WATER ZONES(de th); 11
TONY R DAVIS Top e.) Bottom Top Bottom
Weil Contractor(Individual)Name Top Bottom I Top Bottom ,'I
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name
1481 LARRY DAVIS ROAD 1 Thickness!
7. CAS NG: Depth 'Diameter WeightMaterial
Street Address • Top / Bottom�� Ft. 24 1.5Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code —
( 704) 276-3434 •
Tap Bottom Pt..
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: .. Top 0 Bottom 20 Ft, Concrete Truck
WELL CONSTRUCTION PERMIT#. ../ 0441,.1 I Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(!f applicable) . • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply l - Top Bottom Ft. in. ' in.
DATE DRILLED' Top Bottom Ft.'. : In. in.
TIME COMPLETED e. 6 AM�M O Top Bottom _Ft. In. in.
4.WELL LOCATIO a+yy�AA ,,`` 10.SAND/GRAVEL PACK:
CITY: ,, FtLe COUNTY //` e6/0 Depth $I a Material
Top 2� Bottom�S' Ft.' 71-M Gravel
1 1 030 L Z �i1. 2 Sae Top Bottom Ft l •
Street Name,Numbers,Community,Subdivib on,Lot No.,Parcel,Zp Code) Top Bottom _Ft.: '
TOPOGRAPHIC/LAND SETTING: (check appropriate box) .
❑Slope [Walley [ �1t❑Other 11.DRILLING LOG
LATITUDE , 4iRIqge
.2.5 DMS OR 3X.XxxXXXxxX DD Top Bottom Formation Description
LONGITUDE... . / 40
.��1 ^DMS OR 7X.XXXXXXXXX DD i !
Latitude/longitude source: la
map / _
(location of wall must be shown on a USG S fopo map andattached to �l
this form if not using GP5) / ,
5 ELL O NER -- I.��
AA ;g, - JAJ v�� o l tom, :.. r .7,
O7cô
Name g 1 i i -t L,'��' R i`1•a° if , ,..
L 4 t y 74044 / JAN I s z1Z4
Street A--ddddre s LC AS C. 2Q
City or Town State Zip Code . / — — - —
Area code Phone number ,
6.WELL DETAILS: i /�
12. REMARKS:
a. TOTAL DEPTH: 7
b. DOES WELL REPLACE EXISTING WELL? YES r0❑ I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ..gG FT, ACCORDANCE WITH 15A NCAC12C,WELL CONSTRUCTION
(Use"+'if AborTpp of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
1r PROVIDED TO THE WELL OWNER'.
d. TOP OF CASING IS Fr.Above Land Surface" '
'Top of casing terminated at/or below lend surface may require I ` AI' 4?• a variance in amordance with 15A NCAC 2C.0118. SI NATURE CERTIFIED WELL CONTRACTOR , DATE
e. YIELD(gpm): 2, METHOD+ F TEST TONY R DAVIS !'
I. DISINFECTION:Type /0�,/�/ Amount Loa NAME
>� PRINTED OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing;
1617 Mail Service Center,Raleigh,NC 27699.161r Phone:Ole)807-6300 I Form /09
Rev.2/09
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