GW1--02818_Well Construction - GW1_20240506

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r� Ili N\ RESIDENT�4L WELL CONSTRUCTION RECORD
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' jf, .(. S North Carolina Depatartent of Environment and Natural Resources-Division2 6 .S J/ of�Z'at it Quality
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' " s1 WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. If ZONES(depth�.y`
TONY R DAVIS Top Bottom ,Tpp _ Bottom
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Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom , 1 Top Bottom
Well Contractor Company Name
Thickness!
1481 LARRY DAVIS ROAD 7. cASI C�, Depth 1 Diameter. WeightCement
Material
Street Address Top I Bottom 1,4 (Ft. 2
LAWNDALE NC 28090 _ Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
( 704) 276-3434 1
Material Method
Area code Phone number 8. GROUT: Depth
Top •0 -Bottom 20 Ft, Concrete Truck
2.WELL INFORMATION: ^�O P /j32 1i -
!F;ELL CONSTRUCTION MI 4/_ 61 Top Bottom Ft.�
OTHER ASSOCIATED PERMIT#(if applicable)
Top Bottom Ft.
SITE WELL ID#;cf applicable) Bottom Ft. _ •In.9. SCREEN: Depth Diameter Slot Size Material
in.
3.WELL USE(Check Ap licable ox): R eidential Water Supply Top Bottom Ft. I in. In.
Top —
DATE DRILLED ,j,./ Top Bottom Ft. I in. In.
TIME COMPLETED AM 0 P"''�
10.SAND/GRAVEL PACK:
4,WELL O TIO Depth Size Material
CITY: ' �� coUN 4 s , : Top ,2O Bottom CX a� Ft.i 78—M Gravel _
O a ��,111P1Aro �' Top Bottom Ft. _ �••
(Street Name,Numbers,Corn unity,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom _Ft.
TOPOGRAPHIC/LA ING: (check appropriate box) 11.DRILLING LOG
OSlope ❑Valley 1 t Rid ❑Other 'Top Bottom i Formation Description
LATITUDE • DMS OR 3X.XXXXXXXXX DO /
LONGITUDE' '1 DMS OR 7X.XXXXXXXXX DD /
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Latitude/longituda source: p5 Qfopographic map �V. ..•. ,.
(location of well must be shown on a USGS topo map andattached to I 1. ; . -• y
this form if not using GFS) L
LZIELL FtFrf1 UIe
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,o �z[J/ cz‘ / C. V 4.- l:
Sfppdssj4 t!V /V .2( I
City or Town State Zip Code •/r
Areacode Phone number 12. REMARKS:
6.WELL DETAILS: I
a. TOTAL DEPTH: l
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I DO HEREBY CERTIFY THAT. THIS WELL WAS CONSTRUCTED iN
e, WATER LEVEL Below Top of Casing: F7. ACCORDANCE WITH 15A NCAC,2C,WELL CONSTRUCTION
(Use'+'if Above oppf Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WELL OWNE
d. TOP OF CASING IS Fr.Above Land Surface'
'Top of casing terminated at/or below land surface may require A i '
a variance in actor ante with 15A NCAC 2C.0118. SIG TL`RE 0 TIFtF_D WELL CONTRACTOR DAT
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e. YIELD Wpm): leETH/ODaO 4EST TONY R .VIS
f. DISINFECTION:Type e 60/i 1 Mount 3„,2 ® PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Proeessiing, Fore,OW-la
1617 Mall Service Center, Raleigh,NC 27699"161,Phone:[phone] i
Rev.2/09
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