GW1--01590_Well Construction - GW1_20240308

s, _12 , .A. RESIDENTL4L WELL CONSTRUCTION RECORD
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'�\`✓"�` North Carolina Depart-neat of Environment and Natural Resources-Division of Water Quality
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� " * WELL CONTRACTOR CERTIFICATION#_ Q-5 6' / q
1.WELL CONTRACTOR: g. WATE ZONES(depn' r
TONY R DAVIS Top Bottom qtrj Top _Bottom
Well Contractor(Individual)Name Top Bottom _ . Top Bottom
DAVIS WELL BORING Top .Bottom , Top Bottom .
Weil Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter. Weight Material
Street Address • Top' r Bottom e Ft 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft.I ' -
City or Town State Zip Code Top Bottom Ft'
( 704) 276-3434 •
Area code Phone number 8. GROOUT: Depth Material Method
2.WELL INFORMATION: /hi
4/6)
Top Bottom 20 Ft. Concrete TruckWELL CONSTRUCTION PERMIT# h Top Bottom Ft.
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OTHER ASSOCIATED PERM IT#(if applicable)
Top Bottom Ft,
SITE WELL ID#(If applicable) . ' 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top Bottom FL .in. in.
I Top Bottom FL in. in.
DATE DRILLED - i'a^., _ Top , Bottom Fti. in. in. _
TIME COMPLETED 1 2 t 0 AM 0 PM is}�-
4.WEL 0 ATION: 10.SAND/GRAVEL PACK:
f� Depth �y Size Material
CI : iti y Va f41 COUNTY Top BottorrJ Ft. , 78—M Gravel
q P !o Top Bottom Ft.
((((Street Name, um rs,Community,Subdivision,Lot No..Parcel,Zip Code) , Top Bottom Ft. —
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11.DRILLING LOG
QSlope OValley at °Ridge Other 'Top Bottom Formation Description
LATITUD XX -
�e"DMS OR 3X.XXXXXXX DO
LONGITUDE. a "DMS OR 7 X.XXXXXXXXX DD / __ ,
Latitude/longitude source: PS pi apographic map - I I '+, v,t L..i. �,+ .r
(location of well must be shown on a USGS topo map andattached to I I -on7
this form not using GPS)
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5.W LE410..
r614/E 5p t! 12,4 i iti a. i „ _,:, •ar-.-,..,.e.r.gc,to USN
O er NameXACI /
q . r - - /-
Street Address � ����+ /
t� Ca fSPY vc� F I f
City or Town State Zip Code /
Area code Phone number + 12. REMARKS:
6.WELL DETAILS: �r
a. TOTAL DEPTH:`� •
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b. DOES WELL REPLACE EXISTING WELL? Yaff ►.0 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing: FT' STANDARD$ AND THAT A COPY OF THIS RECORD HAS BEEN
(Use"+'if Above Top of Casing PROVI D TO THE WELL OWN
d. TOP OF CASING IS I FT.Above Land e 0f' 24Top of casing terming ed at/or belw land surface may require P �+a variance inaccordance with 15A NCAC 2C.0118. SI NATUt; CERTI 7 - _ t)_(24.4,1't
ED WELL CONTRACTOR DATE
e. YIELD(gpm): d1. METH D OF TEST TONY R DAVIS 1
f. DISINFECTION:Type Clog]pie. Amount /CO 4 Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit within 30 days of completion to: Division of Water Quality- information Processing, Form GW-le
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2.09