GW1--05102_Well Construction - GW1_20230804

1
Y� '."�' ' : E�'IDENTL4L WELL CONSTRUCTION REco�RD
' '~''_t ' Ji North Carolina Department of Environment and Natural Resources-Division of Watterr Quality
WELL CONTRACTOR CERTIFICATION# 2 ep-15/9 - /--q
1.WELL CONTRACTOR: g. itAlg ZONES(deg th):
TONY R DAVIS Top Bottom i Id Top Bottom
Well Contractor(Individual)Name Too Bottom Top _ Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1461 LARRY DAVIS ROAD T. CAS N : Depth I4 Diameter lWeight Material
Cement
Street Address Top' Bottom Zl7.Ft.
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Coda Top Bottom Ft. _
( 704) 276-3434 Material Method
Area code Phone number 8. GR QUT: Depth
2.WELL INFORMATION: as. '/ i✓ r) Top U Bottom L0 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(itapplicable) •
Top Bottom Ft.
•
SITE WELL ID#(if applicable) . • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check A piicable Box): Residential Water Supply
Top Bottom Ft, •in. in.
Top Bottom Ft. in. In.
DATE DRILLED
Top Bottom Ft. in. in.,
TIME COMPLETED Am AAA❑ P
d.WEL OCA 0P4 : 10::SANDIGRAVELt PACK i
� Depth £Ize NPaterlel- .
e: OUN !, jJ•b,® To ® Bottom; / Ft 71=M 'Gi~a•vel
CITY. •e > �� -
� old��+ �Je 2g, ToP. Bottom Ft
(Street Name,Numbers,Community,Subdivision,tat No:;;parcel,Zip Code) Top . Bottom Ft:
TOPOGRAPHIC 1 LAND .ING:(check approp ata box) 11'.DRILLING LOG '
0 Slope 0Valley at 0 Ridge 0 Other •Top Bottom Formation Description
E / DMS OR 3X.XXXXXXXXX DD ..f . r d'O it 2 u da^—
ATITUD_ lc_ `�. : �r
LONGITUDE I . °OMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: Id -S Qropogr'aphic map / AUG n ,, 2023
I 'u _ �ULJ
(Iodation of well must be shown on a USGS topo map andattached to _
this form if not using GPS) / t^` r "r1-' 'r= ""-• unit
�t y �* f r�laaoo,1.
5.WEsirt (.PSs�d
4,4r
r k G.m 241 ^.7� by ,zs+ / .
/
et Add es . i ott1 c 20-log 1---
City or Town
Area code Phone number 12. REMARKS: ,
6.WELL DETAILS: v r01
a. TOTAL DEPTH: LP
b DOES WELL REPLACE EXISTING WELL? 1ES 0 NQrET I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC_2C,.WELL.CONSTRUCTION
c. WATER LEVEt:'Be1ow?op of Casing F r: STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+•if Abairpp of Casing)' , PROVID D THE WELL OWNER
.d TOP OF CASING IS 11 •FT.Above Land Surface` 'Z'S ®` �'f.
"Top of casing terminated at/or below land surface may require ,"'�"�
D
a variance in accordance with 15A NCAC 2C:0118. Si ATURE �CERTiFIED WEL_t CONTRACTOR ATE
e. YIELD(gpin): METHpD CF TEST _ TONY R DAVIS •
f. DISINFECTION:Typ +Amount ((9 V Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699.161;Phone:[phone] Rev.2/0S