GW1--01599_Well Construction - GW1_20240308

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7'`, Cl ltE�,>IDENT V�ELL CO:ti:ST:RLC1'IO'RECORD
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i`I ,,. tr ,¢` North Carolina Department of Environment and Nahum Resources-Division ofj Water Qua;ity.
`�.�"". � WELL CONTRACTOR CERTIFICATION 4w — LSD fq
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1.WELL CONTRACTOR: g. WATER ZONES(d th)I:
‘I'ONY R DAVIS Top Bottom( Top Bottom
Well Contractor(Individual)Name I�`
, Top Bn tom Top Bottom • __
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name _ -------
1483. LARRY DAVIS ROAD Thickness/
7. CASING:,isNOr; Depth r 7,-!�, Diameter Weight Material
Street Address Top "`" ,/ Bottom Ft. 2 1.5 Cement
LAWNDALE NC 2809.0 Top Bottom Ft.
City or Town State Zip Code I — -- ---
t 704) 276-3434 Top Bottom
Area code Phone number B. GROUT: Depth - Material Method
2.WELL INFORMATION:0 7,.. 20 gn�J� ^ 55 Too 0 Bottom_ 20 Ft, Concrete �'�'ti_k
WELL CONSTRUCTION PERMIT# ' Top Bottom FL _
OTHER ASSOCIATED PERMIT#(+f applicable) Top Bottom Ft.
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SITE WELL ID#{tf appilhle) ' 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top__ Bottom _Ft. .In. in.
DATE DRILLED ° q Top Bottom rt. In. in.
TIME COMPLETED ' . 0 ,,,- AM 0 P,VI Top Bottom Ft. in. in. —`��
4.WELL LO ATION; /'� 10.SAND/GRAVEL PACK: '
s. f COUNT'R.� Depth Size Material
CITY: Top ,Bottom ,Ft. 78—M Gravel
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6 / 3 L i t-tX). 4 V Top Bottom _Ft.
( treat Name,Numbiers,Community.Subdivision,Lot No.,Parcel,Zp Code) Top Bottom Ft.
TOPOGRAPHIC/LAND ING: (cho:k appropriate box)
GSicpe GVaEiey �U laldge Other 11.DRILLING LOG •
LATITUDE - C ' ` 2 DMS OR 3X.XXXXX)CXXX DD °p / Bottom ..:- Four anon Description
LONGITUDE"+ 1 ' �� 'e DMS OR 7X:XXKXXXXXX DO
! ;- 4 ^•
Latitude/longitude source: Dropographic-nap
(location of well must be l own on a USGS topo map andattached to .._ / MA 202 tnis fom;if not uein GPS) I u[
S. ELL OWNER . ._..._.f....._..... _I M;,
an&Nac, ! �
id
S e t Addr ss r —
City or Town Stale Zip Code . / �'—
Area code Phone number
6.1NELL DETAILS; 12. REMARKS:
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a. TOTAL DEPTH: I
b. DOES WELL REPLACE EXISTING WELL? YES G NO •
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 1f 1 FT. ACCORDANCE WITH IBA NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPYOF THIS RECORD HAS BEEN
d. TOP OF CASING IS FT.Above Land Surface*
PROVFID ,TO THE WELL OWNER.
`Top of casing termina ed floc below land surface may require a 0,/ _• - L
a variance in accordance with 15A NCAC 2C.0118. 1d�4��9fi i
SI NATURE ERTIFIED'WELL.CONTRACTOR DATE
e. YIELD(gpm): gft.". , -METHOD OF TEST TONY R DAVIS I
f. DISINFECTION:Type 4g)1\lI mount 1 G► 0 Z 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 27699-161,Phone;(61 E9 607.6300 1 ' om GW-1 a
I Rev.2109