GW1--04193_Well Construction - GW1_20230706

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j�e, �'�11 . ESIDENTIAL w11LL CONSTRUCTioN RECORD
sS Y 'f: '. r�9i
I.) f North Carolina Department of Environment and Natural Resources-Division of Water Quality
��°` WELL CONTRACTOR CERTIFICATION# 2 /9 ~
1.WELL CONTRACTOR: g. WATE ZONES(depth); Bottom
TONY R DAVIS Top Bottom ,.S Top
Top Bottom Top Bottom_
Well Contactor(Individual)Name — —:- Bottom,
DAVIS WELL BORING Top Bottom__
Top '
Well Contractor Company Name ' Thickness!
1481 LARRY DAVIS ROAD _
Street Address 7, CAST G: Depth Diameter Weight Material •
Top ' l Bottom �CiFt. ' 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code Top _Bottom Ft.
704) 276-3434 •
8. GROUT; Depth Material Method
Area code Phone number 0 Bottom .2p Ft. Concrete Truck
2.WELL INFORMATION: ) Top Bottom Ft
cad 9 r t.
WELL CONSTRUCTION PERMIT#23
Top Bottom Ft. •
OTHER ASSOCIATED PERMIT#(ir applicable)
SITE WELL ID#(if appiicable) • • 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. .In. In.
3.WELL USE(Check Applicable Box): Residential Water Supply�..� Top Bottom FL in. in.
DATE DRILLED Top Bottom Ft. in. in.
TIME COMPLETED _ AM❑ PM
10.SAND/GRAVEL PACK:
4.WELL L CATION: J r� wU J� Depth Size Material
COUNTY(�, +G�` Top .Q Bottom bC,Ft• 78—M Gravel
CITY: �L�-- r © ` I �
Q ! 4R4 I G.9 Top' Bottom. Ft.
(Street Name,Numbers,Community,Subdivieon,Lot No.,Parcel,Zip Code) Top Bottom Ft. •
TOPOGRAPHIC i'LAND SETTING: ( hest appropriate box) 11. DRILLING LOG
CSlope OVailey mar ❑Rid•e ❑Other Top gLttorn Formation Description
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aia11/, '' , Z.;DMS OR 3X.XX)0ODXCXX DD I
i_ATfiUDE GGll _�� ! - s "y��
17MS OR 7X.XXXXXXXXX DD
LONGITUDE "° A._ - `---'1•- i1,-q o -g—ri
Latitude/longitude source: r 'S [Topographic map
(location of well must be shown on a USGS topo map andattached to J�� . [���
this form if not using GPS) / In`^
5.WELL OWN RL� .OA7X t y 7ON,Q..6'o� rre.� n,
`Ow�teCNa3me
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° Z. r �' o� /
Street r° s /�4e
i C .2'5'1/‘ .
City or Town State Zip Code /
C—_ ) - .
Area code Phone number 12. REMARKS:
n.WELL DETAILS: j j /I '
a. TOTAL DEPTH: SI `/LJ
b. DOES WELL REPLACE EXISTING WELL? YES NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: / U FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"t'If Aba P of Casing) PROVIDE TO THE WELL OWNER,
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated a or below land surface may require
' a variance in axordance with i5A NCAC 2C.0118. SI ATURE ATI SE WE ..CONTRACTOR DATE
e. YIELD(gpm): METHOD,OFF TEST /' TONY R AVIS
f. DISINFECTION:Type 0 gi mount /Ley Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form 2/09 1a
1 617 Mall Service Center, Raleigh,NC 27699.161,Phone : (919)B07.6300