GW1-2022-06491_Well Construction - GW1_20220603

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SC CN�
RESIDENTL L WELL CONSTRUCTION RECORD
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North Carolina Departrnent of Environment and Natural Resources-Div: ion of u'a•�er Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: P. W ER ZONES
T'ONY R DAVIS To Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom _ Top_ Bottom
Well Contractor Company!Jame Thickness!
1481 LARRY DAVIS ROAD 7. CASIN Depth Gianeter Weight Material
Street Address ^ Top Bottom.$I-Ft. 24 1 .5 Cement
LAWNDALE NC 2809Q Top Bottom Ft.
Cty or Town State 4ip Code
( 704) 2 7 6-34.34 _ Top Bottom FE.
Area code Phone number I B. OR UT: Depth Material Method
2.WELL INFORMATION: ` ` Top U Bottom 20 Ft Concrete Truck
WELL CONSTRUCTION PERMIT#S ` �++ 5 —J Top Bottom Ft.
OTHER.ASSOCIATED PERMIT#(If eppfieable) Top Bottom Ft.
SITE WELL ID#(rf applicable) 9, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Resideenfial Water Supply❑ Top oottom Ft. in. in.
DATE DRILLED ~ V _ V Tap Bo"E cm Ft. In. in. _
Top Bottom Ft. in. In.
TIME COMPLETED a 3JO AM El PM
4.WELL LOCATION: 10.SANDIGRAVEL PACK
1 % Depth' Size Material
CITY: d04O.UNTY_^ �'/�� :
� -To VBottom t. : 7$-M Grave.
Top Bottom'' Ft.`
(Street Name,Numbers,Conm!jnity,'Subd'M5ien,Lot No..Parcel,4p Code) Top i3otiotn• Ft.
TOPOGRAPHIC/.LAND Nu: (check appropriate box)
ClSiope ❑Valley at ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formatior,Description
LATITUDE I S OR 3x.XXXCOD=DD
LONGITUDE- S OR 7x.)o=xxxxx DD -
LatitudeAonMtude source: PS Qropographic map
(Iccabon of well must be shown on a USGS topo crap andattached to !1 rA r
this form if not using GPS) i 09 _
S.WELL OWN ME
..y
jwner Name
G
Sit ee�tAeddras
City or Town State Zrp Code /
U - 1 l�
Area code Phone number
i2. REMARKS:
6.WELL DETAILS:
a, TOTAL DEPTH:
I
b. DOES WELL REPLACE EXISTING WELL? YES O NQ I DO HEREBY CERTIFY THAT THIS WELL WAS'CONS.RUG T ED IN
c. WATER LEVEL Below Top of-Casing: FT• ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCT!ON
(Use'+'rf Above op of Casale) STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN .
.. -, : : NER.
d. TOP OF CASING IS' 1- Above Land Su ace' TO TN PROVIDED E-.VvE'L OW
'Too of casing,terminated atlor below land surface rray�equue
a variance in accordance with 15A hJGAC 2C.Of 18: i. �? � -- - 2 e
� � I
SIGN URE OF CER D Vd_LL LO,'V I RACTOR ` `"DATE
'e:YIELD,(gpm): METHOD FTEST ! 99 TONY R DAVIS.
f. DISINFECTION:Type 4.0unt i
4 PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Dlvisionlof Water Quality- Information Processing, Form wd•.a
1617 Mail Service Center, Raleigh, NC 27699-1611 Pho�e:[phone] Rev.2I09