GW1--00635_Well Construction - GW1_20240119

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C z �ti' RESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of Environment and Natural Resources-Division of Water Quality
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��`4��"""" WELL CONTRACTOR CERTIFICATION# / (Q ...
1.WELL CONTRACTOR: g. WATER ZONES(de th): ,
TONY R DAVIS Top 2 Q Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom • ' !P, Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name - -• Thickness!
1481 LARRY DAVIS ROAD 7. CASIN : Depth .441 Diameter Weight Material
Street Address • Top ( Bottom.. G Ft. 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom' • Ft. ' .
City or Town State Zip Code Top Bottom Ft. 1.
( 704) 276-3434 .
Area code Phone number 8. GROUT: Depth • Material Method
0i%2.WELL INFORMATION: Top . �-� 20 Concrete Truck
� Bottom Ft.
WELL CONSTRUCTION PERMIT#.23 0. .2,2 ' - . - . Top Bottom Ft. .
OTHER ASSOCIATED PERMIT/NI applicable) Top Bottom ' Ft.
•
SITE WELL ID#('rf applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply$ Top Bottom Ft. ; .in. " in.
DATE DRILLED 1 I �' / I r` 23 Top Bottom Ft ( , in. in.
Top Bottom Ft. ' in. in.
TIME.COMPLETED ! 3- G 0 AM ElPM�' -•
4.WELL LOCATI N• 10.SANDIGRAVEL PACK:
9 _ e1� �n 20 Depth Size Material CITY: V n ( COUNTY Li Z Top Bottom yLFt.' 78—M Gravel
2 .3 . ' ''ay
Q A?e rplivC�' Top Bottom FL
(Street Name,Nu s,Community,Subdivision,Lot o.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box) I •
11.DRILLING LOG •
❑Slope ❑Valle y �Pidt'❑Ridge ❑Other �'
'Top Bottom Formation Description
LATITUDE - 9/(9 DMS OR 3X.XXXXXXXXX DD /
LONGITUDE. .-3.25DMS OR 7X.XXXXXXX0X DD / - -
Latitude/longitude source: i Qropographic map /
(location of well must be shown on a USGS topmap andattached to
this form if not using GPS) /
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5.W npOWNis / Vl y re� /
0i,,, v1 er N me
3 Ari it—IPX fZer Pi. l JAN 202
Street Ad ess �� ` /
V PO?Z / uN Ai C / _ :-.:`-r ____;r_ -1`:
City or Town State Zip Code / ,
U - /
Area code Phone number
12. REMARKS:
6.WELL DETAILS: , /�
a. TOTAL DEPTH: !� !.
I / 1.
• b. DOES WELL REPLACE EXISTING WELL? YES 0 NCeEr"
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
j c. WATER LEVEL Below Top of Casing: 0 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
) _
(Use"+"if Above Top of Casing STANDARDS,AND THAT A COFY:OF THIS RECORD HAS BEEN
PROVIDE TO THE WELL OWNER. a1
d. TOP OF CASING IS , FT.Above Land Surface /r / (7
"Top of casing terminated at/or below land surface may require J
a variance in actor ante with 15A NCAC 2C.0118. SI ATURE CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD'QFTEST 3 TONY R DAVIS I . _•
f. DISINFECTION:Typ -'Amount.VLf 0 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 27699-161,Phone:[phone] 1 I Rev.2/09