GW1-2023-00448_Well Construction - GW1_20230109

E,SID,ENTIAL WELL CONSTRGCTIol1`RECORD
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Nona,Carol;rz Department of Environment and Natural F;:ources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
I
1.WELL CONTRACTOR: g. VNER ZONES( ih):
TONY R DAVIS Top__ _Bottom CS Top Bottom
Well Contractor(Individual)Name Top Bottomi Top Bottom,
DAVIS WELL BORING Taa _Bottom Top_Bottom
Well Contractor Company Name
1481 LARRY DAVIS ROAD. Thickness/
7. CA$: Depth Diameter Weight Materia)
SireetAddress •�L, ''4 1.5 Cement
LAWNDALE ToF Botto. L
NC 28090 Top Bottom Ff."
City or Town State Zip Code 704 27b-343!+ Top Eotfom Ff.
t _
Area code Phone number &. GROUT: Depth Material Method
2.WELL INFORMATION- t Top 0 Bottom 20 _F't. Concrete Truck
WELL CONSTRUCTION PERMiT;#1 "� Top Bottom Ft
OTHER ASSOCIATED P=RMIT*(Ifapplicable) . Top Bottom Ft.
--
SITE WELL ID f:(fi applicable) S. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential UJatet SuppWe� Tap Bottom _ Ft in. in.
DATE DRILLED d Tap 3ottom Ft; in. in, r
TIME COMPLETED ? Top SFttom Ft!` in. in.
d.WELL L CATION: 10 SANDIGRAVEL PACK
Depth `$ a .; :Notarial
CITY COUNTY Tc?p, f~ptt6m, 7$-M Gray eI
1 Topr _ Boft FY
(SUeei Na^tie Numbers Communrt�Subdiw on Lot,No -Parce,Zp; -Top Bottom Ft
o
TO?OGRAPHIC/.L,AN�DS NG (check appioPna�s boz)
CSlope pValley 61'r ,bkiiage-pother 11 DRfLLIfvGLOG— -
Top' b'ettarn' Fo.-m t",n Descnptiop
LATfr(JDE: _0.;' DIA'S 0R11 ax xmax�;xx DD
LONGITUDE. 0 - `"
�re�-+"-$ JMS 0 7 e•�
R X.XXXXXXKXX
�.,�
Laiitudelfongitude source: 5 Ci'opographic map
'(tomffon of well must be shown on a USGS topo map andattached to / iIj
this form tf not using GpS) /
S.INEL OWNER
Owner Nammd
rzet Address
City o own Sta a Zip Code /
Area code Phone number
6.WELL DETAILS: 12.-REMARKS:
a. TOTAL DEPTH:
t
b. DOES WELL,REPLACE EXISTING WCLL? .YES NO❑
I DO HEREBY CERTIFY T HAT THI5 WELLINAS CONSTRUCTED)Iv
c. ,W,�rER LEVEL.Below Top of Casing; ; ACCORDANCc MT_H 15A NCAC 2C,WELL CONSTRUCTION
(iJse rf;A6ove Top, f'G6sini3) . STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN
PR �� D Tfl"1 I iE 1h>:LL OWNER.
d TOP OF CAS1NG IS 'r1 Above Land Surface• l J
Tap of casing tel �d atlorbelow land surface may require- r• Pf
a vanance m acco a'ice'witti 15A NCAGcC 4115
SIG' �U - ERTIFIED LL CCtd fRAC i DR
' t
YIELD(gpm) METHOD__TEST A - TOA'Y• R DA'V,S :..� I s
f DI5INFEC,TION:Typ / �irnount,
PRINTED NAME—OF PERSON CG:NSTkUCTING THE WELL'
-
Submft with In 30 days of completion to'. Division.of Water Qilaii,ty--irtfotm3tion ProcessiFrg
1617 Mail Service Center, Raleigh;NC 27699.161,Phone: [phone]t?8 iI Form GW-1a
Rev.2109