GW1--02216_Well Construction - GW1_20240409

"i� l� N,, RESIDENTIAL WELLC TRL CTION RECORD
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$'�\ G North Carolina Department of Environment and Natural Resources-Division of Water Quality
' a...e1, WELL CONTRACTOR CERTIFICATION## -�5Cy
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1.WELL CONTRACTOR: g. W T`ER ZONES(ii t 1 ;�
TONY R DAVIS Top 4.1 ( .BottonL, 1. ' Top _Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top -Bottom i , Top Bottom .
Wail Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASs G: Depth Diameter_ Weight1. Cement
Material
Street Address • Top'° / Bottom Ft.
LAWNDALE NC 28090 Top_•„_Bottom Ft,I • — • —
City or Town State Zip Code Top _Bottom Ft,_; + -_
( 704) 276-3434
Area code Phone number • 8: GROUT: Depth Material Method
2.WELL INFORMATION: Top Bottom 20 Ft, 'Concrete " Truck.
WELL CONSTRUCTION PERMITa3'". "'I,6/0 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(it applicable) Top_ Bottom Ft: 1 •
SITE WELL ID#(If applicable) • 9. SCREEN: Depth Diaiiteter Slot Size Material.
3.WELL USE(Check Ap iica le Box): Residential Water Supply M../ Top Bottom Ft. I' ' .in. � in.
• DATE DRILLED '` Top Bottom Ft.! in. In,
Top Bottom Ft, In. In.
TIME COMPLETED 0 AM D PM V,-�--
10.SAND/GRAVEL PACK: I
4.WELL LOCATION:Cwti, Top BDoepotnh ' ''Size
CITY: 1.7. CouN1'YZ/1d 4a e Material
- Gravel
�F Q All • p-tt 10 7 r7 2 J Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No..Parcel,ZIP Code) Top_ Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 19.DRILLING LOG •
GSlope ON/alley W;iel' 0Ridge ❑Other Top Bottom ' Formation Description
LATITUDE3$'•• ',—.j') "DMS OR 3x,Xx)0000CXX DD /
LONGITUDE ', d5 6 "DMS oi?7X.XXXXXXXXX Do / ,
Latitudellongitude source: JAV6S Topographic map /
(location of well must be shown on a USGS lope map andattached to / '
this form if not using GPS) I I { .
ij� ,� / I ! APR �� 92r_44 __.
:,WELLOVYNERiii �} y�u lJ:i+l� S
t
Own rName Diiy,L; 'L ;
itI • &/4p.y15 pao4f - I , .
rest Address /
�0 v� Al C., 2 ..3?' /
City or Town State Zip Code " /
( I
Area code Phone number 12. REMARKS:
G.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO�J./ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
J
c. WATER LEVEL Below Top of Casing: `/1 t 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
PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS FT.Above Land Surface' �9, t �
'Top of casing terminated at/or below land surface may require f�
a variance in accordance with 15A NCAC 2C.0116. SI ATURE�ERTIFIEI JELL CONTRACTOR DATE
a. YIELD(gpm): METHOD OF TEST TONY R DAVIS I i
f. DISINFECTION:Type I l Amount/16 O Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ii
Submit within 30 days of completion to: Division of Water Quality- Information Processing; Form GW-la
1617 Mail Service Center,Raleigh, NC 27699.161,Phone:[phone] I Rey,2/oy