GW1-2021-03527_Well Construction - GW1_20210607

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liCSI.DENZTM WELL CONSTRUCTION REC IR>7
North ep
h Carolina Dm=::nt of Envimntnent and Natural Resources-Division of Water Quality
A
.WELL CONTRACT OR CERTIFICATION it
1.WELL CONTRACTOR: g. WATER ZONES(depth):
It 49
TONY R DAVIS Top_ Bottom . Top Bottom
Well Contractor(individual)Name Top _Bottom Top ° Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD T. CASING: Depth ,Diameter Weight Material
Street Address Top _Bottom,Zi Q Ft 24 1.5 Cement
LAWNDALE NC 28090_ Top Bottom Ft
City or Town State Tip Code Top Bottom Ft
t 704) 276-3434
Area code Phone number B. GROUT: Depth Material Method
2.WELL INFORMATION: ] �o Top O Bottom 20 Ft: Concrete Truck
WELL CONSTRUCTION PERMIT# / VVL Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applcable) Top Bottom FL
SITE WELL 10"applicable) 9. SCREEN: ,Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential 1A ater Supply j2.-- Top Bottom Ft' Jn. in.
Top Bottom
DATE DRtLLE ' Ft in. in.
Top Bottom Ft: in, in.
TIME COMPLETE Lze AM O PM
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
Depth 461ze Material
CITY: couNTY Top go_Bottom -4Z Ft. 78-M Gravel
�,,� �� Top Bottom Ft
(SUW 4arrie,Numbers,Community,Subdivision,Lot No. P , p Code) Top Bottom Ft
TOPOGRAPHIC I LAND SETTING: (cha*appmapriala bax) 1.1.DRILLING LOG
Oslope ❑Valley fip" oRiiddge 1:)Other Top Bottom- Formation Description
LATITUDE ,,. T �DMS OR :'X.XXx)OW00t DD / o
LONGITUDEr �'��r''I—t-�-+W "MS OR l X.XXXXXXXXX DD
/
Latltudeflongitude source: l Qropographic map
(location of well must he shown on a USGS topo map andalfachedto !
this farm ff not using GPS)
5.WELL OWNER , / Ea -t v "L-,
- owner Name � / .111N _
J g /_1 I
re / ll���rr at;e;� rcce
/ j Lv °
City or Town State Zip Code /
U /
Area code Phone number 12, REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YES D N0dj",i : I DO HEREBY CERTIFY THATITHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 2 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•H Above lop of Caging) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d TOP OF CASING IS FT.Above land Surface
'Top of casing termina tlor below land suuace may require
C=�/� ,S
a variance in accordance with 15P,NCAG 2C.0118. S NATURE O CERTI�WELL CONTRACTOR DATE
e. YIELD(gpm): _METtioD of TEs7 TONY R DAVIS I
f. DISINFECTION:Type f Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
$Ubmftwithin 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,INC 27699-161,Phone:(919)$07-6300 Rev.2/09
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