GW1-2021-02500_Well Construction - GW1_20210805

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s .,[l. `SID.EARrML WELL CONSTRUCTION RECORD
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North Carolina Bepart;ntnt ofF.rmviianmcnt and Natural Resources-Division of Wafer Quality
WELL CONTRATOR CERTIFICATION A
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1.WELL CONTRACTOR: P�ZONES(de h'
TONY R DAVIS To Bottom i Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WEI,L BORING _ Tap Bottom Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CAS Depth lDiameter Weight Material
Street Address To Bottom Ft.i 24 + 1.5 Cement
LAWNDALE NC 28090 Tap Bottom Ft.L
City or Town State Zip Code Top Bottom Ft-
704 t 276-3434
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top O Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT#�_. Top Bottom Ft. _
OTHER ASSOCIATED PERMIT#(ifapplicabie) Top bottom Ft
SITE WELL ID#(d applita ale) 9. SCREEN, Depth Diameter Slot Size .Material
3.WELL USE(Chefk Applicable Box): Residential V later Supply rg.. : Top Bottom Ft! In'. in.
DATE DRILLED .. Top Bottom Ft! In. In.
Top Bottom Ft In. In.
TIME COMPLETED AM© PM�„r•►� '
4.WE CATION: 10.SANDIGRAVEL PACK:
Depth Slze Material
CITY v V COUNTYr. Top " ottomAed Ft 18—M Gravel
''�/+'� 1���� 4►� 't"� Top m Botto fit.
/.�(-SL�roet—�Name, umbers,CommMft,Subdmftn,Lot No. ,ZIP Code) Top 8otfam Ft.
TOPOGRAPHIC I LAND SETTING: (check epproprirse box)
C)Slope DValley pOWA* ❑Ridge 00ther 11.DRILLING LOG
�/�� /���i /� 'Top Bottom Formation Description
LATITUDE 2011L�+O OMS OR X.XXXXX)O=OD
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LONGITUDE °0�2.,.t 23DMS OR?X.WOOO XXX DD
Latitudellsongitude source: 4OWQTopographic nap
(location of well mast be shown on a USGS topo mast andat(ached to
this form If not using GPS)
1
5.W ie311.�
J nO�wrer Nam /r �f''`�+�� ! 'i.ACro
'~—•--
` Street A doe j A1N[{b
Ctgr or own Stara Zip Code
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH,•
b. DOES WELL REPLACE EXISTING WELL? YES O NOd--� i c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing; �. ACCORDANCE_WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+•if Above op of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIPqP TO THE WELL OWNER /
d, TOP OF CASING IS L _ FT.Above Land Surface'
`Top of casing terminated atfor below land surfs ae may,require {
a variance in accordance with 15A NCAC 2C A i 18. SfGNATURE OrCERTIFIED WELL CONTRACTOR DATE
S. YIELD tgpm): METHOD OF TEST TONY R DAVIS E
f. DISINFECTION:Type / GAmoun.� PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to:Division of Water Quality- Information Processing, Form oW-1a
1617 Mall Service Center,Raleigh,NC 27699-i8t,Phone:[phone] � t Rev.2/09