GW1--03280_Well Construction - GW1_20230511

s yP v.. �1 .RESIDENTIAL WELL CONSTRUCTION RECORD
`�'' y r North Carolina Department of Environment and Natural Resources-Division of Wateleir Quality
ww.d'� F. .w. 7.
..
WELL CONTRACTOR CERTIFICATION#
•
1.WELL CONTRACTOR: g. WATER ONES(de th):
TONY R DAVIS Top , Bottom Top Bottom
Well Contractor(individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Wet Contractor Company Name • Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter 24 Weight CementMaterial
Street Address Tcp', 1 Bottom_14Ft,
LAWNDALE NC 28090 Top Bottom Ft._, .
City or Town State Zip Code Top Bottom Ft.
7041 276-3434 - -
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top O Bottom 20 Ft._ Concrete Truck
'�+ C1550
WELL CONSTRUCTION PERMIT Top Bottom_ Ft._
OTHER'ASSOCIATED PERMIT#(if applicable) Top Bottom Ft, •
SiTE WELL ID#[d applicable) • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check A iicable Box): Residential Water Supply p Top o Bottom Ft._ in. in.
TOP------f3oriom� Ft: In. in.
DATe.DRILLED '27 "
f\ Top Bottom Ft In. In.
TiME COMPLETED Q-V `AM L PM . ..' ~
10 ..-_.
4.WEL i CA.TION: SANp,,, D EL PACK
Q" Depth -&tze Matertah
city:'." A) 'COUNTY 4',�'uP���" Top Bottom Ft 78 M; Gravel
n ; . "tr
. '8'5' ra:flu Lda $G 9a Top _Bottom ,Ft.
(Mimi Name,humbes,CommuruTy,Subdwision;Lot No.;Parcel,Tip Code Top Bottom Ft
TOPOGRAPHIC f LAND,S s ING:;:(che.k appropr'ate bpi)
0 Slope 0Va11e 0Ridge DOther 11. DRILLING LOG
'Top Bottom Formation Description
_.tATITUDF . XX)
DMS OR 3X. 0(X)OOOC DO /
LONGITUDE of "DMS DR 7X.)000000 DD / ..,
Oi....4 t
Latitudeilongitude source: 1 .-Qrapographla map ! 3"_ �.e; .+y'y,.. ...'...
(l ai.on of well must be shown on a USGS topo•map,andatiached.to I r_:�-�..
tilt formTf riot using GPS) . .. -, _023
" n^
/. 1 .'2)4 U eSrati e IQ rb : . NO j ..
5 L 01M1iN1c
ri y .oa7-• 2ap.. ,
r7Jess7
AIL /
/,�
,City'orTown •_ • State,,, Zip Code, /
L ' te 2' /
e .Phone number _. . -
12. REMARKS:
6.WELL DETAILS: Li / ;
a. TOTAL DEPTH: Le
b,:DOES WELL REPLACEEXISTiNG WELL? YES D. N04�
f DO HEREBY CERTIFY THAT THIS:WELL WAS.CONSTRUCTED IN ---
•:a WATER LEVEL Below.Top of casing : . . FT.= ACCORDANCE WITH 15A NCHC 2C,WELL CONSTRUCTION
(Use,°+,.it,Above Top of Casing): .. STANDARDS;AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO ThE WELL OWNER
s� D
cl T0P OF CASING i5 'Frt Above Land 5u-face' _
Top of casinta terminated aor below rand surface may.require LCIA .J 23
a variance in accordance with 95A NCAC 2C.Ot 18. ; SIG A.TUR�E aFCERTIFIED WELL CONTRACTOR
e YIELD(gpm):..; . ` .MErWOID OF TEST :.: ,. . • TONY R- DAVIS- • -,. -- - _ `.. .
. .
f. DISINFECTION:Typ A , L
mountr 0 Z. PRINTED NAME OF.PERSON CONSTRUCTING THE WELL •
Submit within 30 days of completion to: Division of Water Quality- information Processing, Form GW-la
1617 Mall Service Center;Raleigh;NC 27699-161,Phone :[phone] Rev.2/09