GW1--03989_Well Construction - GW1_20240708

l,- .. . c RESIDENTIAL WELL CONSTRUCTION RECORD
' ',��' ,4 ` -` North Carolina DeparUnent of Environment and Natural Resources-Division of Water Quality
. 26 5i J
` WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g. WATER ZONES(de `r):
TONY R DAVIS Top 24. Bottom Top Bottom
We'l Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Welt Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CAS N : Depth Diameter Weight Material
S:rec:tAddress • Top''( Bottom_Ft. 24 1.5 Cement
LAWNDALE NO 28090 Top— Bottom Ft.
City or Town State ZIp Code Top Bottom Ft.
c 704) 276-3434
Area code Phone number 8. GR UT: Depth Material Method
2.WELL INFORMATION: r) Top `�dttam 20 Ft, Concrete Truck
WELL CONSTRUCTION PERM �t L.) 9 v - Top Bottom F>_.
OTHER ASSOCIATED PERM.IT#(Y,applicable)
Top Bottom Ft.__r
SITE WELL ID#(tf applicable) •
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check pFi+cable Box): Residential Bottom Ft. in. in.
�l Water Supp.
Top Bottom Ft, in. in.
DATE DRILLED '" . Li
�r Top Bottom Ft. in. In.
TlMt:COMPLETED — ANIo(d� M
10.SAND/GRAVEL PACK:
4.WELL LOC T10N: Cj �L y� gppth Size Material
CnY: COUNTY LT Top Blottor,�� Ft. Size Gravel T
tJ V
t -2_ L /ts 7 Top Bottom Ft.(Street Name, mbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) Top_ Bottom Ft.
TOPOGRAPHIC/LAND ING: (checx appropriate box) 11.DRILLING LOG
p Slope D'Jaliey :at O Ridge rl Other4f. Top Bottom Formation Description
LATITUDE 3'9 .. ) L'f41S OR 3x.?OCXXXXXXX DO - /
—
LONGITUDE of i7 , .DMS OR TX.XXXXXXXXX DD
Latitude/longitude source: ;•"S ['Topographic map
(location of well must be shown on a USGS top map andattached to J 4 __ if
this form,f not using GPS) l _I."
5,WELL OWNER I
it '' ;
r �'� 2i 1 ,EG ..I1l1 Az J J_ irhv ,�.. ,I,yi ; JTF
4
er Name 5 i?+1� :,`+�.;
J
Qdess 0 9 i S 26)33I) I
City or Town / State Zip Code • / --
(.._....) / —
Area code Phone number 12. REMARKS: ,
6.WELL DETAILS:
a. TOTAL DEPTH:b. DOES WELL REPLACE EXISTING VrELL7 YES C NO��.."--' 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 0 FT. ACCORDANCE WITH 15A NCAC 2C.WELL CONSTRUCTION
(Use's'if Above op of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PP.OVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' 22. /�
'Top of casing terminated at/or below land surface may require �•L�t ___. t� .a[
a variance in accordance with 15A NCAC 2C.0118. S NATtr; ' CERTIFi ,ELL CONTRACTOR DATE
�i�i e. YIELD(gpm): METH470 OF TEST TONY R DAVIS
f. DISINFECTION:Type Amount _ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information.Processing, Form GW-la
1.617 Mail Service Center, Raleigh, NC.27699•161,Phone :{S1e)807-6300 Rev.2/09