GW1--02212_Well Construction - GW1_20240409

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ell 1�, ' RESIDENTL4L WELL CONSTRUCTION RECORD
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u North Carolina Department of Environment and Natural Resources Division of Water Quality
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WELL CONTRACTOR C)EIZTIFICATIOI�'#
1.WELL CONTRACTOR: g. W T€R ZONES(deptt} 1
TONY R DAVIS Top 1 Bottom "17J Top Bottom
Well Contractor(Individual)Name Top Bottom i 1 Top Bottom
DAVIS WELL BORING Top Bottom_ I Top Bottom .
Well Contractor Company Name • iy Thickness/
1481 LARRY DAVIS ROAD . 7. CA IN G: Depth Dla24ter Weight Cemeent
Street Address 1 ' Top' / Bottom�� Ft. I I
LAWNDALE NC 28090 Top Bottom Ft. I '1
City or Town State Zip Code Top 'Bottom Ft
704) 276-3434 • 1
Area code Phone number 8. GROUT: Depth t-Material Method
Top O
2.WELL INFORMATION: Top 20 Ft, Concrete Truck
WELL CONSTRUCTION PERMI Til V !' /-.,_ Top Bottom Ft., 1
OTHER ASSOCIATED PERMIT#Of applicable)
Top Bottom Ft. I
11.
SITE WELL ID Cif applicable) . • 9. SCREEN: Depth Diar1rteter Slot Size Material
3,WELL USE(Cheek Applicable Box): Residential Water Supply ice"'
Top Bottom Ft I' I •.in. ' in.
� /,- 2' Top Bottom Ft.f 'I In. in. _
DATE DRILLED o, Top Bottom Ft.i, li in. in.
TIME COMPLETED / 41 ! 60 _ M O PM 2:1,.--- .
10.SAND/GRAVEL PACK: ',
4.WEL° LOCATION: } Q�N Depth i ,Giza Material
;iTY: ADZE _CDUNTrL Top Bottom r' Ft._ 78—M Gravel
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fjLQ(,. / (1� _- G 9 Top Bottom Ft)
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zp Code) Top Bottom Ft!' I
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
11. DRILLING LOG •
0 Siopa ❑Valley gi ieto'd Ridge 0 Other Top Bottom Formation Description
LATITUD .' DM5 OR 3X.XXXXXXXXX DD / I, r,
LONGITUDE ( ,; "DMS OR 7X.XXXXXXXXX DD /_ t ,. `, {,,�.
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Latitude/longitude source: I
S DID map
. (location of well must be shown on a USGS topo map andattached to
this form if not using GPS) / I 1 APR 0 9 2021
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`6ate -- N( 31.1 1 Il2 21c / .
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0;2er Nari &4Y
AI'llrn Pee _ . _ ._
S ee `ddress - _
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>w _ /v C 2[JJ66 /
City or Town State Zip Code ,' ! I
L._._J - / I
Area code Phone number 12. REMARKS: I
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6.WELL DETAILS:
a. TOTAL DEPTH:. ' 'I
b. DOES WELL REPLACE EXISTING WELL? YES O NO&' I II
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing:_ 44( FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
! PROVIDED O THE WELL OWNER,
d. TOP OF CASING IS IL I FT.Above Land Surface' i I.1
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*Top of casing terminated at/or below land surface may require f 1 ' '
a variance in accordance with 15A,NCAC 2C:0118. SIG ATURE 71 IED WELL ONTRACTOR DATE
e. YIELD(gpm) ,METHO OF TEST / TONY R AVIS I i
f. DISINFECTION:Type( a Amount Ili PRINTED NAME OF PERSON `CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- information Processing, Form GIN-la
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] II Rev.2/09
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