GW1--05928_Well Construction - GW1_20230918

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I
PI t' - { RESIDENTIAL WELL CONSTRUCTION RECOIRI)
,,,, £,.r cY3 North Caro:,ina Department of Environment and Natural Resources-Division or V,'iater Quality
,", I WELL CONTRACTOR CERTIFICATION# a G i
•
1.WELL CONTRACTOR:
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TONY R DAVIS e. ZONES(ae h)l
Top Bottom Top Bottom
Well Contractor(Individual)Name Top -Bottom �' I. Top Bottom
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DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name
1481 LARRY DAVIS ROAD 7. CASi G: Depth 4.±_24 Diameter Weight Thickness1 Material
Street Address • Top Bottomys 1• Cement
LAWNDALE NC 28090 Top Bottom Fi r
City or Town State Zip Code
L 704) 276--3.434 Top Bottom Ft.
Area code Phone number B. GROUT: Depth Material Method
2.WELL INFORMATION: r .1 h3 / a� Top 0 Bottom 20 Ft. - Concrete Truck
23
WELL CONSTRUCTION PERMMIITJ•#�6'I Top Bottom_ Ft. .
OTHER ASSOCIATED PERMIT#(ifapplicable) Top Bottom Ft.
SITE WELL ID*Of applicable) j
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Cheek pplicabf Box): Residential Water Supply Top Bottom Ft� .in. in.
•DATE DRILLED ))� Top Bottom
Ft. in. in.
TIME COMPLETED l.3 a G AM❑ PAM1,{ Top_ Bottom Ftl in. -- In.
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4.WELL LOCATION: ( 10.SAND/GRAVEL PACK:
• CiTY:gur�G(sgi~ J�.� COUNTY (Jai �y Depth i •Size Material
^� /� ' 1 / T Top2OO Bottom 45 Ft. 78—N Gravel.
....7 2! G.,A /I' RO G k f""A Top Bottom Ft.
(Street Name,Numbers,Community,SubdMsion,Lot No.,Parcel,Zp Code) Top Bottom Ft.
TOPOGRAPHIC?LAND SETTING: (check appropriate box)
0 Slope DValtey 01Fiat ❑Ridge C}Other 11.DRILLING LOG l
f 51 QJ_/ Top Bottom Formation Description
LATITL'O4J t#C "DMS OR 3X.XXXXXXXXX DD / i
LONGITUDE( ' 1(1��? ('DMS OR 7x.XXXxxxxxx DD / I' . "
Latitude/longitude source: Eti�'S []Topographic map /
(location of well must be shown on a USGS topo map andatfached to I
this form if not using GPS) / —( ii .. t-7:4 ; `i i a
SWELL OWN
KR
ai►�1 y NkkYN j �pr 1 SEP 1 8 2073
..... IN�mec As d y A c.),k Rcvill_ _ / • CJVYs f..v.X
Street Addr ss / .or e.p,i..07LA AAC
City or Town State Zip Code ' /
( ) / I•
Area code Phone number
S.WELL DETAILS:
• 12. REMARKS: I'
a. TOTAL DEPTH: 4 5
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b. DOES WELL REPLACE EXISTING WELL? YES<O 0
I DO HEREBY CERTIFY ThAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: C7 FT. •ACCORDANCE WITH 15A NCACr2C,WELL CONSTRUCTION
(Use"+"if Abov Top of Casing) STANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN
1( PROV TO THE WELL OWNER:
d. TOP Op CASING IS FT.Above Land Surface" R i F,I
`Top of casing terminated at/or below land surface may.require
a variance in accordance with 15A NCAC 2C.0119. S NATUR RTIFIED WELLCONTRACTOR DATE
e. YIELD(spm): METHOD OF TEST TONY R DAVIS ' i
f. DISINFECTION:Typ , Amount s PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality.. Information Processing,
1617 Mail Service Center,Raleigh,NC 27599-161,Phone:(919)80T-9300 ! FormGW 1a
Rev.
2/09