GW1-2022-10234_Well Construction - GW1_20221111

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Y 1-t RESIDENTUL WELL CONSTRUCTION RECORD
'•v �i" % North Carolina Depart:nen:of Environment and Nvaral Resources-Division of W at uality
WELL CONTRACTOR CERTIFICATION it —Z—0 �S i
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P
g. WATER ZONES(depth):
1.WELL CONTRACTOR: Top Bottom^„ Top Bottom
TONY R DAVIS Tap Bottom
Well Contractor Bottom —Contractor(individual)Name Bottom Top Bottom
DAVIS WELL BORING TQp
Weil Contractor Company Name Thicknessi
7. CAST G: Depth Diameter Weight Material
1481 LARRY DAVIS ROAD Bost t !24 1.5 Cement
Start Address Tap
LAWNDALE NC _ 28090 Top Bottom Ft.
— City or Town State Zip Code Top_Bottom. Ft— —
( 7� 276-3434 a. GROUT: Depth Matertai Method
Area coda Phone number ® T op 0 Bottom 20 Ft. Concrete Truck/
2.WELL INFORMATION: !f !�
�/ Top Bottom Ft
WELL CONSTRUCTION PERMIT Top Bottom Ft_'
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID Kif appfirable) _ S. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. In.
3.WELL USE(Check p(icabi Bo�x•):,Residelrtial Water Supply❑ Top Bottom Ft in. in.
DATE DRILLED tt/1JJ• ••/G'f..�� Top Bottom Ft. in, in.
TIME COMPLETED ! AM D PM�i}+^�
10.SANDiGRAVEL PACK:
4.WELL } I 'CG`N : _ Depth Stze Material
ciT,: /�ry/�+ffVV�`O L dd ® IJ COUNTY�(� �J ,�• Top ottom t. 7 —M Gravel
Top Bottom Ft.".
tS+.reet Name,Numbers,Community,Subdivision,Lot No.,PWZip Top Bottom Ft.—
TOPOGRAPHIC/LAND NG: (check approofte box) 11, DRILLING LOG
pStope pValiey -at,�'�R"dge pother Top Bottom FortnaSonDesCriptl°n
LATITUDE j f DMS OR 3X.xxxxx) =DD
S OR 7x.-=xxxxw DD f
LONGITUDE / f
Lathudeilongitude source: Qr°pographlc map
(location of well must be shown on a USGs topo map andattached to I
this form It not using GPS)
- S.w OW 00
Very r 1 NOV_I--1 �-----
eT) bAj t1� rj&1.q P4� r
1 �an Prx
sI-If
AddrrrsC t�7a �l �'G 2$ g e
Stale Zip Code f
City or Town !
Area code Phone number 12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH-
b DOES WELL REPLACE F)CI5TING WELL. YES�NO CJ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ,FT. ACCORDANCE WITH 1,6A NCAC 2C,WELL CONSTRUCTION
(Use"+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
f PROVIDED TO THE WELL OW ER.
d. TOP OF CASING IS FT.Above Land Surface' .
,Top of casing terminated atlor below land surface may require
a variance in accordance with iSP.NCAC 2C.Ott8. 81GNA URE 0#C JELL COAcaTO&RA DATE
e. YIELD(gpm}: METHOD OF TEST T0Iv1' R DAVIS
f. DISINFECTION:Type Awount : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 34 days of completion to: Division of Water Quality- Information Processing, Farm cW-Ia
... .,,��� 4C4 o►,.,.,s •ro1a1 Rn7.F3nn i Rev.2109