GW1-2021-04250_Well Construction - GW1_20210419

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.l.�.LiS'IDENTlAL WELL CONSTRUCTION RECORD
L North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: g• WATER ZONES(de?` ):
TONY R DAVIS
TO
LIMSBottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thicknessl
1451 LARRY DAVIS ROAD 7. CASING: Depth Diameter weight Material
Street Address TopBottamt' 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 704; 276-3434 --
Area code Phone number B. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft, Concrete Truck
WELL CONSTRUCTION PERM[T# l — V 0 2 To' Bottom Ft.
OTHER ASSOCIATED PERMIT#(i<applicable) Top Bottom Ft,
SITE WELL!D#(rF applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box), Residential Water Supply ppo— .: Top Bottom Ft._In. in.
DATE DRILLE f � Top Bottom Ft in. In.
TIME COMPLETED _ AM❑ PMZ_� Top Bottom Fti in. In.
4,WELL LOCATION: 10.SANDI'GRAVEL PACK:
' �A�.� (('O NTY Depth Sire Material
CITY: L.j O�.t(. ��v//7�� Tope' Bottom,S�Ft. 78—M Gravel
Top Bottom Ft.
(Street Name,Numbers,C ontm u—A!;ion !%No. Parcel,Z p e) Top Bottom Ft.
—
TOPOGRAPHIC/LAND SETtING: (check appropriate box)
CSlope ❑Valley �ORidge Other 11. DRILLING LOG
'Top Bottom Formation Description
LATITUDE - "�DMS OR 3X.V.XXX)O=DD /
LONGITUDE MS OR 7X.XX)000XXXX DD /
Latitude/longitude source: Qfapogrephic map /
(location of well must be shown on a USGS tops map andattached to /
this form if not using GPS)
5.WELL OWNE
Gl y 1 9 2021
Owner Name
`A�f'�j� )�A ,y t�E^.£?SS!t?f� Unit
StreelAdd g V��ar " J 1 L-
City or Town ` State Zip Code /
U /
Area code Phone number
S.WELL DETAILS: 12. REMARKS:
a. TOTAL DEPTH:� �
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO i;j�:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N
c. WATER LEVEL Below Top of Casing:O�g;; FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•tf Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED 0 THE WELL OWNER.
d. TOP OF CASING IS �. -,
F f.Above Land Surface"
'Top of casing terriow land surface may require
a variance in accordance with 15A NCAC 20.0118. GNATUR CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):, METHOD OF TEST TONY R DAVIS
f, DISINFECTION:Type ount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sufsmitwithin 30 days of completion to: Division of Water Quality- Information Processing,
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:(919)SOT-t334D Form GV4'-1a
Rev,2109