GW1-2021-00320_Well Construction - GW1_20210312

.�ESIDENT74L WELL CONSTRUCTION RECORD
North Carolina Depat4nent of Environment and Natural Resources-Division of Wafer Quality
WELL CONTRACTOR CERTIFICATION
1.WELL CONTRACTOR: g• WATr=R ZONES(de th
TONY R DAVIS TO t% 2,8otiom_ low;000
Top Bottom
Well Contractor(individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom To
Well Contractor Company Name P Bottom
1481 LARRY DAVIS ROAD Thickness]
7. CASING: Depth Diameter Weight Material
Street Address Top Bottom Ft 24 1.5 Cement
�AWNDALE NC 28090 Top Bottom FL
City or Town State Zip Code
t 704) 276-3434 Top Bottom Ft.
Area code Phone number 8. GR OUT: Dept Material Method
2,WELL INFORMATION: Top Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# qq� Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(xapplicable) Top Bottom Ft,
SITE WELL ID#(rf applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply aw— Top Bottom Ft. in. in,
DATE DRILLED �� Top Bottom Ft. in in ,
TIME COMPLE rEb ,4N ❑ pAA ToP 3ottoin Ft." iri. In
4.WEL LOCATION 10.SANDIGRAVEL PACK
CITY: , t`OU a Depth 6fze'. Materlai
Top­�2fbftom` t` 78 M: Gravel
' Top Bottom Ft.
(Slreel Na -e,Nu bars,Community,Sub rfton,Lot No:,Parcel,Zip Code} Top Bottom Ft
TOPOGRAPHIC!LAND SETTING (check appropriate box)
❑Slope GValley QPA..,6Ridge [)Other 11. DRILLING LOG
LATlFUDE lj�.' ir:DMS OR 3X.)OcbcX)OpOt DO
Top Bottom Formation Description
/
LONGITUDE`S" 2-DMS OR 7X.)o-=oo=DD 1
Latitude/longitude source: gyp%7-0rcPog raphic-map
(locaBon of well mustbe shown on a USGS fopo map andattached to I .,
this form ifnot using GPS)
S.WELL OWNER
Owner Name /
at Address
Ity or Town State Zip Code
9 .
Are code Phone number
S.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL. YES p N0
` t0 i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: M •ACCORDANCE WITH'I5A NCAC 2C,WELL,CONSTRUCTION
(Use`T'rf Above Top of Casing) STANDARDS,AND THAT A COPY OF,THIS RECORD HAS BEEN
_ L } �1111VIIIEDT THEWELLOWNER.
d. TOP OF CASING IS_T [ FT,Above Land Surface*
'TOP of casing terminated atlor below land surface may require
-"a variance in accordance with 15A NCAC 2C.0118.
SIGN URE F; TIFI WELL CONTRACTOR DATE
e. YIELD(gpm) METHOD OF TEST TONY R DAVxS
f. DISINFECTION:7YFe 4" Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitwithin 30 days of completion to: DiVision of Water Quality- Information Processing,
1617 Mail Service Center,Ralelgh,NC 27699-161,Phone :[phone]DO Form GN-1a
Rev.2109