GW1-2022-01296_Well Construction - GW1_20220112

-�� � �s� l�ESII�LNTIAL WELL CONSTRUCTION RECORI}
North Carolina Deparnner+t of Environment and Natural R'es^oJJu-ces-Division of W ater Quality
WELL CONTRACTOR CERTIFICATION# '
g. WATER ZONES(dept ):
1.WELL CONTRACTOR:
TONY R DAVIS - Top %Bottom �-- ;Top Bottom
Well Contractor(individual)Name
Top Bottom Top Bottom
DAVIS WELL BORING Top BottD-11 Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7., CASING: Depth Diameter Weight Material
Street Address Top Botto��Ft.
24 1.5 Cement
LAWNDALE NC 23090 Top Bottom Ft._
Cit or Town
State Zip Code Top Bottom Ft.
f 704� 276-3434 8. GRQuT:
Area code Phone number Depth Material Method
20 - Concrete- Truck
2,WELL INFORMATION: Top 0 Bottom tt��
WELL CONSTRUCTION PER MIT#
w� Top Bottom FL
Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(N apPlicablei
SITE WELL ID#(rt applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply�r
Top Bottom Ft. in. in.
Q J Top Bottom Ft. in. in.
DATE DRILLED ' o f
Top Bottom Ft. in. in.
T11AE COMPLETED-1.7-04 . AM 0 PMAa —r "
10.SANDIGRAVEL PACK:
4,WELL LOCATION: v Depth 8tge Material
Cm; COUNTY��G'b`/V Top,�_Botto ;7�Ft.' 78-M Gravel
J �JPR Top Bottom Ft.,,.
(Street Name,Numbers,Community, ubdiv,sion,Lot N5.,Parcel,Zip Code) Tap Bottom Ft.r
TOPOGRAPHIC i LAND S • NG: (check appropriate box) 11. DRILLING LOG -
E:Slope I_valley 6ptir ❑Ridge 00tner - Top Bottom !Forrnation,Descriptlon
L ATITUDE, , .a2— DMS OR 3X-XXXXX)0=DD
LOIdGITUDE ��a DMS OR 7X.XXXXXXXXX DD
Latitudehongitude source: grviime''Qlopographic map
riocation of well must be shown on a USGS topo map andattached to
this form if not using GPS) / !
Ow er Name /
�La
Street Addre ,i"��
� t ¢i�.f p,( l
City or Town State Zip Code /
Area acode Phone number 12. REMARKS-
G.WELL DETAILS: :
a. TOTAL DEPTH:. �,�+
t. DOES WELL REPLACE EXISTING WELL? YES Nu C I DO HEREBY CERTIFY THAT r-JIS WELL,NAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEER!
(Use`+`if Above Top of
PROVIDE 0 THE WELL C1h NER.
d. TOP OF CASING IS �FT.Above Land Surface' �� ��"
'Top of casing terminated aVor belcw land suuace may require
0"a variants in acro dance with ISA NCAC 2C.0118. r��TLPCERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD of TEST TONY R DAVIS
f. DISINFECTION:Type Amount Q PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
submit within 30 days of completion to, Division of Water Duality • information Processing, Form GW.1a
1617 Mail Service Center, Raleigh,NC 27699-161,Phone :[phone]DO Rev.2109
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