GW1-2023-00524_Well Construction - GW1_20230109

RESIDENTIAL WELL CONSTRUCTIOi!RECORD
Nor'it Carolina Department of Environment and Nato al Resoum cgs-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
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1.WELL CONTRACTOR: g. WATER ZONES(depth
TONY R DAVIS Top1 Bottom. Top ;�ottam
Weli Contractor(Individual)Name Top Bottom _ Top Bottom
DAVIS WELL BORING Top Bottom _- Top Bottom_
Well Contractor Company Name Thickness/
148Z rt,ARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top sottom Ft, 24 1.3 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code Top -Bottom Ft.
i 704 276-3434 _
Area code.Phone number 6. GRCO T: Depth Material Method
2.WELL INFORMATION: n Top iottom 2O Ft. Concrete Truck
WELL-CONSTRUCTiON PERASIT# 12 /Q - Top - -Bottom - - Ft._�
OTHER ASSOCIATED PERMIT#(tf applicable) Top Bottom Ft.
S(TE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable 8ax): Residential Water Supply 9-- ; Top ,Bottom Ft.! in. in.
DATE DRILLED +- 1 ' �. Top -Bottom Ft. In. in.
J— Top Bottom__,Ft.! In. in.
TIME COMPLETED AM O PM fG�
L CAT10�I: 10.SAND/GRAVEL PACK:
4.WELL,
Ll Depth ! Size Material
CITY: COUNTY L/�iU Top�.Bottomar`' Ft. 7$M Gravel
��.�� � ��•HO�`�j. Top Bottom Ft.
(Street Nime��um'6errs/Cclm. unity,Subdivision,lat No.,Pd,cel,7jp ode) Top Bottom Ft.
TIOPOGRAPH2,/LAND S G: (check saproprio,e box)
❑slope QVailey at ORidge DOther 11.DRILLING LOG
Top Bottom Formation Description
L.ATtTUDE _ DMS OR 3X.XXXXXXXXX DO /
LONGITUDE.�._ �fDMS OR 7X.XXXXXXXXX GD - ,, -•-- -�——
Latitudeliongitude source: PS Oropographic map / '- ^ - Y- s `)
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) ! -- J A N G 7071
5 WELL OWNER 0
er Name , f
& /
St Addre s
- - -
Ctty of Tuwn State Zip Code /!
Area code Phone number
: 12. REMARKS:
G.WELL DETAILS:
a. TOTAL DEPTH:_ — —_
b. floes WELL REPLACE EXISTING WELL? YES J N04,--- : I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: y FT. m ACCORDANCE NITH 15A N6 0 2C,WELL CONSTRUCTION
(Use'+°if Above Top of Casing) STANDARDS,AND THAT CbP'Y OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 151_hT.Above Land Surface' t
'Top of casing terminated at/or below land surface may require I�+�tr'4f�•6./ �L ��
a variance in accor nce with 15A NCAC 2C.0116. IGNATUXFOF CERTIFIED-WELL CONTRACTOR DATE
e. YIELD(gpm):, METHOD OF TEST TONY R DAVIS i
f. DISINFECTION:Type Z&4Amount PRINTED NAME OF PERSON,CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Process ng, Form GW-1a
1617 Mall Service Center,Raleigh,NC 27699-161, Phone;[phone] I Rev.2/09
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