GW1--00581_Well Construction - GW1_20240118

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s�Y �' 7 t1 RESIDENTIAL WELL CONSTRUCTION RECORD
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\ '1 i ° North Carolina Department of Environment and Natural Resources.Division of Water Quality
1':« '� WELL CONTRACTOR CERTIFICATION# LQSL2_LL9_-
iop...._ONES1.WELL CONTRACTOR:
TONY R DAVIS Top BottomBottom
Top —Bottorn Top Bottom
Well Contractor(Individual)Name Bottom__ Top Bottom,
DAVIS WELL BORING Top
f Thickness/
Wel!Contractor Company Name Diameter Weight Material
1481 LARRY DAVIS ROAD 7. cASJNC�: Depth 24 1.5 Cement
Top --F•—Bottom,..Ft
_
Street Address
LAWNDALE NC 28090 Top Bottom Ft. ,
City or Town State Zip Code Top Bottom Ft
( 704) 27673434 • e. GROUT: Depth Material Method
Area coda Phone number p Bottom Ft. •0 Bottom 20 Ft, Concrete Truck
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Top
2.WELL INFORMATION: ,4JaT(.iJtiLA„ { To
WELL CONSTRUCTION PERMIT# Top Bottom Ft. '
OTHER ASSOCIATED PERMIT#(if applicable) •
SITE WELL ID Nit applicable) ' ' 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. .in. In.
3.WELL USE(Check Applicable x) Re 'dential Water Supply Top Bottom Ft. in. in.
DATE DRILLED �� � Top Bottom Ft. in. in.
TIME COMPLETED DO - AM 0 PMl
4,WELL 0 TI0 Depth 10.SAND/GRAVEL PACK: -Size43 Material
�,' COL'N Top Bottom FL 78—g1 Gravel.
CITY: X gG.
Tap Bottom Ft.
(Street02363 se,Numbers,Community,Subdivision,Lot No.,Parcel,Tip Code) Top Bottom Ft,
TOPOGRAPHIC/LANDS ING: (check appropriate box) 1'I,DRILLING LOG
❑Slope 0Valley JJ tt Other
Top Bottom • Formation Description
LATITUDE __(1IA
DMS OR 3x.XXXXXXXXX DO
1 'CMS OR 7x.xXXXXXXXX DDLONGITUDE a I/ .."''= r� �Latitudeilongitude source: opographic map !� 7�,,,e ��i. �y E rl
(location of well must be shown on a USGS topo map andaftached to JAN . LOL
this form if not using GPS) 1
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6.WE OWHERR �t ( 'r °;''.
15' �P`� tfhv�r=rwt:,t r� •' .,1 t
,t :� �`.
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OwnerNa a __ �A�al� p i- ,
S Mcitirld143
13 Co 215 . �_
City or Town State Zip Code 1
Area�code Phone number 12. REMARKS: _'
6.WELL DETAILS: te3
a. TOTAL DEPTH: �I ' i
b. DOES WELL REPLACE EXISTING WELL? YES to NO V I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c, WATER LEVEL Below Top of Casing: 2 ' FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above To of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
g PROM 0 THE WELL OWNER. /Or/O . 3
d. TOP OF CASING IS, 1 FT.Above Land Surface' 00,44*0
W.
'Top of casing termin ted at/or below,land surface may require
a variance in accordance with 15A NCAC 2C.0118. SI ATURE 0 RTI 1E0 WELL CONTRACTOR DATE
METHOD OF TEST_ TONY R DAVIS 1f
e. YIELD d Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
f: DISINFECTION:Type Amount Cj
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Submit within 30 days of completion to:Division of Water Quality- information Processing, Fov.
1617 Mall Service Center,Raleigh,NC 27699.161,Phone:(919)9D7.6300