GW1--04125_Well Construction - GW1_20230623

1
W( J ,��' RESIDENTIAL WELL CONSTRUCTION RECORD .
1%, ��., A Noah Carotin a Department of Environment and lvratural Resources-Division of V,later Quality
` �` WELL CONTRACTOR CERTIFICATION# -2 6_.5(9 "-
1.WELL CONTRACTOR: g. W TE ZONES(de ):
TONY R DAVIS Top, Bottom '1 0 Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name •
1481 LARRY DAVIS ROAD Thickness/
7. CASING: Depth Diameter Weight Materiel
Street Address Top J Bottom g Ft. 24 1..5 Cement
LA4,WNDALE NC 28090 Top Bottom Ft. _
City or Town State Zip Code Top . Bottom Ft,
( 704'. 276-3434 —
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: f Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# ( � 612' 36 Top Bottom -Ft '
OTHER ASSOCIATED PERMIT#Lf applicable) Top Bottom Ft.
SITE•WELL ID#(if appli able) • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply l Top Bottom FL :in.: - in;
el
DATE" DRILLED Top_ Bottom. Ft. in. in.
, 0 Er Top'. ..Bottom - Ft: in _ in
TIME 3CMPLETED ,f: /,r•_. CAMPM .
4;:WELL .QCATiON: 10 SAND/GRAVEL PACK
?/'�� .y! �+ _f :Depths] Q;' :'Size Material
CI'Y. �!`*`"'��YJ e 7 /� COUN'rY'R, �/g/'�i7�' Top Bottom !art •'78=M Gravel
21 + '7: ,• & 1I ` 2 a/3 ? Top Bpm tto 4 - .•
(Srreat.Nam Numbers Com
munity,Si:, '•ion,Lot No.;Parcel,up.Code) Top - Bottom Ft. ,- -,
TOPOGRAPHIC/.LAND ING: (check appropriate box)
❑Stop= OValley at ❑Ridge ❑Other 11_DRILLING LOG _
t-�Qp Top Bottom Formation Description
LaTITLD '�0 •...�fllr"DMS OR 3X.XXXXXXXXX DD /
LONGITUDE - ° 030 "DMS OR 7X.xxxxxxxxx DO /
LatitudeJIongitude source: i Dropographic•map 1
(location of well must be shown on a USGS topo map andattached to / I a''-,r:""'r.-'‘r--r.- f,-,r.vh
this form if not using GPS) / I ;: C
5.WEUOWNER J /
i.u 9 2,a,u M,� i i fu Je / JUN 2023
Owner Name /
/
SireetAddress
7 u 77 cg 1c0RJ it) . Ai .2 / q / _.
City Dr,Town :r.-:::''State:'' Zip Code
is
l ). /,
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a..TOTAL,DEPTIi: 2 g - ' - • •
_ _ •
b.:D.OES.WELL REPLACE EXISTING,WELL?: YES 0.:: NOD,.'
I DO;HEREBY CERTI•FYTHAT THIS WELL-WAS CONSTRUCTED IN
c t WATER.LEVEL Below Tap of Casing 63 FT : ACCORDANCE WITH H 15A NCAC 20,WELL CONSTRUCTION --'`-`--•
r <(Use + ir;Above To of Casin STANDARDS AND THAT A COPY OF THIS RECORD HAS-BEEN
PROVIDE ,0 THE WELL ,OWNER. ._'
d„TOP OF•,CASING IS 1 FT.Above Land Surface*
Top of casing terminated at/or below land surface may require �fF
23
.a anarce in accordance with 15A.NCAC 2C.C118'.'• � `CONI OR ' E
S NATUR =CERTIFIEDV�ELL CONTRACTOR ' CATE
e :Y1ELD:(gpin)i. METHOD DP TEST TONY R DAVIS . • ' -
f. DISiNFECTION:Typft-"Amount 1 i� Vz PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-la
1617.Mail Service Center, Raleigh, NC 27599-161,Phone:[phone] Rev.2/09