GW1--00636_Well Construction - GW1_20240119

3
,�`,1 %"'r •, ;!1 .t.(�.SYDENTZ L WELL.CONSTRUCTION RECORD
\W f, -(�' " z.. North Carolina Department of Environment and Natural Resources-Division of Water Quality
``:w.. WELL CONTRACTOR CERTIFICATION# 4y'- j9 I's- r t
1.WELL CONTRACTOR:
TONY CONTRACTOR:
DAVIS g. aTiiR,ZONES N4'o
•
• Top 1 ,Bottom Top Bottom
Wel!Contractor(Individual)Name
DAVIS WELL BORING Top Bottom Top _Bottom
Well Contractor Company Name Top Bottom Tap _Bottom
1481 LARRY DAVIS ROAD Thickness/
7, CA t Depth Diameter Weight Material
Sbeet Address • Top Bottom,, Et. 24 1 .5 Cement
LAWNDALE NC 28090 �
City or Town Top Bottom Ft.
State Z)p Code Top Bottom Ft. ~
( 704) 276-3434 -
A ea code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: C
Top Bottom 20 , Concrete Truck• _
WELL CONSTRUCTION FERMIL� d �� Top Bottom Ft.
OTHER ASSOCIATED PERMIT*(if applicable) Top Bottom -Ft. .
SITEWELL ID*Of applicable) ' • 9. SCREEN Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): „�Residential Water Supply O� Top Bottom Ft. .in. in.
DATE DRILLED l 9C/� X Top Bottom Ft. in. in.
TiM°COMPLETED F-3 f 0 _ AM t i PMS Top Bottom _Ft: in. in.
I
4,WELL LOCATION: 1,��+ 1 y 10,SAND/GRAVEL PACK:
CITY: Q/h° 744 �►, COUNTY v'+UP7 ,4 ,tAA Depth Size Material - -
�9 f Toptef .Bottom ( Ft. ' 78-M Gravel
d f 1 a ? G.w 4 6 .i Top Bottom Ft. ���
Street Name,Numbers.Community,Subdivision,Lot No.,Paroel,Zp Code) Top Bottom Ft. _
TOPOGRAPHIC I LAND SE�i?1N (ct_ck appropriate box) .
OSlope ❑Valley itFlat oge ❑Other 11. DRILLING LOG •
'Top Bottom Formation Description
. LATiTUD 1,�' "DMS OR 3x,x: XXXXXX DD /
LONGITUDE'_ ,/ '5' DMS.OR/''X.XXY,XXXXXX DD I _
Latitude/longitude source: Gropographic map / •
(location,awe!?must be shown on a USGS topo map endatteched to ' • -�
this form if,rot using GPS) I l d Lo -''' f.,/';~'�
5.WELL OWNER _- : -.'*''
J��.,;, ,...,,...,,1.:-.,,,-,-.r..:,,T.::,-, :`
wner Nar e M/J(� / t. _ ..
reet Add s fII
City or Town State Zip Code . / '-'
Areacode Phone number /
12. REMARKS;
6.WELL DETAILS: j ,
a. TOTAL DEPTH: 2 -
-
b. DOES WELL REPLACE EXISTING WELL? YES a N,t --- 1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: ' r FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+`if Above Top of Casing) STANDARDS,AND THAT A COFj Y OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' °�
'Top of casing terminated al/or below land surface may require •• �Su 1637. 3
a variance in accordance with 15A NCAC 2C.0118. CIGNAT "E OF CERTIFIED WELL!CONTRACTOR DATE—
e. YIELD(gpm):_ METHOD OF TEST TONY R DAVIS 1
f_ DISINFECTION:Type / eAmount l V d z PRINTEC NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Qualify - Information Processing, „1
1S17 Mail Service Center,Raleigh,NC 27699-161,Phone :(919}807-6300 RFormev. v�v-la
Rev.2/09