GW1-2023-02316_Well Construction - GW1_20230331

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xy,74 RESIDENTIAL WELL CONSTRUCTION RECORD
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i;, �-�, �= Neri^.Carolina DeparCnant of Environment and Natural Resources-Division of'Water Quality
WELL CONTRACTOR CERTIFICATION# 6_ C 14
1.WELL CONTRACTOR: g. WATER ZONES idept ):
TONT R DAVIS Top, Bottom 4A1 . Top Bottom
Weli Contractor(Individual)Name Top_ Bottom Top Bottom
DAVIS WELL BORING Top Bottom ;_ Top Bottom •
Wall contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING.) Depth / Diameter Weight Material
Street Address Top"4 i Bottom r/ [ Ft. 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom FL :
City or Town State Zip Code
Top Bottom Ft.
t. 7D4) 276-3434 _ - -
Area code Phone number 8: GROUT:. Depth Material Method
2.WELL INFORMATION: �� % Top 0 3oµom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERM'TTM CQd . Top Bottom Ft.
3THER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft. -SITE WELL ID#01 applicable) . • 9. SCREEN: Depth giameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 0 TOO Bottom Ft„�_in. in.
DATE DRILLED t' ' 3 , Top . .: Bottom .: . FL` :in:'.:... •. . _rin . ...,
TIME COMPLE I tD V.V AM O PM C�� Tep �ot+om Ft. in. In.
10 SAND/GRAVEL PACK ... M: rw_
: ��® COUNT ,, ::, .'---..
Lev Yc Topf 36Do0etHpo �rnh Ft $n eM M;gartavae l F
(Street Name,Numbers,Cornrfy,Subdivision,Lot No.,Parcel,Lp Code) Tqp 3otiom- Ft. -
TOPCGI ,FrIIC I La ND Sc ING: (checkcappropriate box) ' :.
nSlope'OVa Iey Ri e Other 11. DRILLING LOG
Top Bottom —Formation Description
LFT ITUD- -.110 ' 0 ?MS OR 3x.xx�oo�ax CD
i
LONGITUDE,let A "DMS OR'X.XXXXXXXXXX DD ,—_
Latitude/longitude source: .= ❑Topographic map
(location of well must be s •wn on a USGS topo map andattached to _I.
this form if not using GPS) /
s.
5.WELL O HER G I � ' .,:. rri ?
,ems7t,AV . .11 (7/4H -
nor Name- d � ,�, t�� _ ✓` _ - IVIHf? 3 I...ZU[,� —
dif
S ss c _/
^—
NS
or Town ., a 2 Ci• 3/o State Zip Code
Area code Phone number.
12, REMARKS: -_.
6.WELL DETAILS: -. ,
a. TOTAL.DEPTH:-
c ____
6. DOES WELL REPLACE EXISTING WELL? YES D NO#r I — --
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c..WATER LEVEL Below Top of Casing FT
ACCORDANCE_IMTN-15A NCAC 2C WELL CONSTRUCTION.._ ....
(Use'+'if Abcv'To dealing) S'ANDARDS AND THAT A COPY O THIS RECORD H"S BEEy _.:
PPOVIDED �;TitE:YJE'LOWN
•
d. TOP OF CASING IS(FT.AboveLand Surface
:.?1"0 of.casin§terminated at/or below land surface may require • .r �� .+L
a variance in accordance with 15/i.NCAC 2C.0118., : S1G ATURE D _RTIFIED WELL CONTRACTOR DATE
a. YIELD(gpm): ETH015 OF TEST - TONY .R :DAVIS ' :"; ' . ,t.. .. . .
f. DISINFECTION:Type I 45,mount 902 / ea PRINTED NAME OF PERSON C,DNSTRUCTII'C THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Process;ng, Form GW-la Mail Service Center, Raleigh, NC 27699-161,Phone:[phone] I Rev.2iO3