GW1--01588_Well Construction - GW1_20240308

'" y ?ESIDENTLA WELL CONS TRUC:TION RECORD
� ,Ty i�:
"' ; ~ ' r North Carolina Department of Environment and Natural Resources•Division of Water Quality
'°�« •4+°''`r WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: -g. WATER d tNtES(de th): ' Top Bottom
TONY R DAVIS Top .3)(4.
Well Contractor(Individual)Name Top Bottom _L Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom _.. .
Well Contractor Company Name 1 Thickness/
1481 LARRY DAVIS ROAD 7. CASI G: Depth Diameter Weight Material
Street Address • Top Bottom (12t.f 24 1.5 _ Cement
LAWNDALE NC 28090 _ Top Bottom Ft.!
City or Town State Zip Code Top_J Bottom Ft.
( 704) 276-3434 a, GROUT: Depth Material MethodArea code Phone number Top 0 Bottom 2C) Ft. Concrete Truck
•2.WELLINFORMATION: �,�
/JELL CONSTRUCTION PERMIT# �. ` Top Bottom Ft.
Top Bottom Ft,
OTHER ASSOCIATED PERMIT#(ifappl(cabie)
•
SITE WELL ID#(if applicable) • ' 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom FLmin. in.
3.WELL USE(Check Applicable Box): Residential Water Supply D Top Bottom Ft; in. in. _
DATE DRILLED ••• • - Top Bottom FL in. In.
TIME COMPLETED a - AM Cl PM '
'10.SAND/GRAVEL PACE::
4.WELD ATION: l Depth ay Side Material •
_
v111 e COUNTY L I►10da1 Top ,LL✓ Bottom p dio !. .t ize Gravel
CITY: 7+ /
L7 / L/� Top BaKom Ft
•
(Street Name,Numbers, immunity,Su vision,Lot No.,Pa I,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND r. f ING: (check appropriate box) 11.DRILLING LOG
❑Siope [Valley at ID Rid.e ■Other Top Bottom Formation Description
LATITUDE _ l .' ±• "DMS OR 3X.X 03°° °°<DD /,_
-
+ 0 ; DMS OR 7X.XXXXXXXXX DD /.-- —'
LONGITUDE 6�a�---- — / , ....... . c Z „.
LatitudeAongitude source: POI Dropographlc map / N. �;�
(location of well must be shown on a USGS topo map andatteched to /
this form tf not using GPS) / NiJ(}( it 8 2024
e
S Lf OWNER
Ki S SPI XrCIw V 1 tM`Ci mSa-ii it ::::sr '•::o nbt
_-
Owner Name
Street Address `it 21 /_
City or Town State Zip Code /
/
Area code Phone number 12. REMARKS:
S.WELL DETAILS: 6 2 I ^'
' a. TOTAL DEPTH:_ —
b. DOES WELL REPLACE EXISTING WELL? /YtES 0 NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: �ti FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use°+•if Above Top of Casing) PROVID D TO THE WELL OWNER.
d. TOP OF CASING IS +1 FT.Above Land Surfaces �y (•••"J�
"Top of casing,terminated at/or below land surface may require L.• ,R
a variance In accordance with 15A NCAC 2C.0118. NATU-e'of CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): MET OD OF TEST TONY R DAVIS
f. DISINFECTION:Typ Amount 1 toe a Z. PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- information Processing, Form OW-la
1617 Mall Service Center,Raleigh,NC 27699.161,Phone:[phone] i Rev.2/09