GW1-2021-01014_Well Construction - GW1_20210419

k
� i
(+ RESID.ENT.rA.E WELL CONSTRUCTION Ri✓CORi}
• �V,, � North Carolina Department of Environment and 13aturai Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# gg4. 04Z �;9
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Topattom�� Top Bottom
Weil Contractor(individuaO Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD T. CAB Nti: Depth Diameter Weight Material
Street Address To Bottom Ft: 24 15 Cement
LAWNDALE NC 28090 Top Bottom Ftl
City or Town State ,_.Zlp.Code `Top Bottom Ft.
( 70 ) 276-'3434
Area code Phone number 8. GROOUT: Depth Material Method
2.WELL INFORMATION: : Top Botlom 2O Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# 3 Top Bottom Ft
OTHERASSQGIATEDPERMiT#(ifapplicable} Top Battom Ft
SITE WELL ID#,(If apprscabte) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply .+""'; Top Bottom Ft' In. In.
DATE DRILLED "" *►� .• Top Bottom Ft. In. . In. -
Ta Bottom Ft�' In, In.
TIME COMPLEf ED •` j AM'O PM�- p
4.WELL LOCATION: - 10.SANDIGRAVEL PACK:
a• •size Material Depth
c�''""�N,, roui�TY CT S f Iy/�hj Top �sotiom '�S--M- Gravel.
/ L 1J V{� 75i.tSTop Bottom Fi_
(Street Name,Numbers,Community,Sub niision,Lot No.,Parcel,Zip Top Bottom Ft.
TOPOGRAPHIC I LAND SET?JNG: (chock epprcOsto lox)
❑Slope DValley 0661oA" Ridgs 00ther 13. DRILLING LOG
'Top Bottom Formation Description
LATITUDE rt•��'� DMS OR 3X.pp%NXXX)t DO /
f W
LONGITUDE .""� 12DMS OR 7X.0X) 00=DO /
Latlludedongttuds source: 203-tropographic map 1
flocation of well must be shown on a USGS topo map andaffached to
this form if not using GPS) l
/
5,WELL .. ' Ar '11 p '
Chv Name
��ress
lrirrq.t;4tit
?� �r
State Z►p Code
GSiy or Town _
Area code Phone number
12, REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:r173
b. DOES WELL REPLACE EXISTING WELL? YESJd-4W0 !DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ED IN
c. WATER LEVEL Below Top of Casing:�FT. ACCORDANCE WITH 1SA NCAG 2C,WELL CONSTRUCTION
(Use'+'If Above Top of Casing) STANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER,
d. TOP OF CASING IS ( FT.Above Land Surface' -.A-,Or
h /
'Top of casing terminated attor below land surface may,require �
^'
a variance In accord nce vnm 1SA NCAC'2C.0118.
SIG#qATURE OFSERTIFIED WELL C NTRACTOR DATE
e. YIELD(gpm):-^-� --- METHOD OF TEST TONY R DAVIS
i
f. DISINFECTION:Type ou ount .PRINTED NAME OF PERSON CONSTRUCTING THE WELL
l
Subrnit within 30 days of completion to:Division of Wafter Quality- Information Process,Ing, Form GW-1a
1617 Mall Service Center,Raleigh,NC 27699-1$1,Phone:[phone]poo Rev.2/D9