GW1--02214_Well Construction - GW1_20240409

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r e v ,i�.ai^ RL:rSIDE RESIDENTIAL WELL CONSTRUCTION RECORD
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Norb Carolina Department of Environment and Natural Resources•Division of Water Quality
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"` a... WELL COi f F FACTOR CERTIFICATION# �.0 -,5I.
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1.WELL CONTRACTOR: g. WATER ZONES(d th):
TONY R DAVIS Top .2 2 Bottom I 'Top Bottom
Weil Contractor(individual)Name Top Bottom _ Top Bottom
DAVIS WELL BORING • Top Bottom I Top Bottom .
Weil Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING1' Depth. Diameter Weight Material
Street Address Top .✓ Bottom / Ft, i "24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft 1
City or Town State Zip Code Top Bottom Ft. 1. 1
704, 276-3434
Area code Phone number 8. GROUT: Depth 'Material Method
2.WELL INFORMATION: .—y Top 0 Bottom 20 Ft._ Concrete Truck
WELL CONSTRUCTION PERMIT `'°3I Top Bottom Ft._
OTHER ASSOCIATED PERMIT#(irapplicable) Top Bottom Ft. , .
SITE WELL ID#(if applicable.) . ' 9, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply E1-0""----- Top Bottom Ft. 1 • •in. in.
DATE DRILLED Top Bottom Ft. I in. In.
Top Bottom Ft. in. In.
TINIE COMPLETED - — AM hi❑ ', ..
10.SAND/GRAVEL PACK: I.
4.WELL L CATIO AJ ,�9/�� Depth Size Material
CITY: ' �' COUN Y������1 Top_ 6 Bottom_$/ FL ', 78—M Gravel •
4 '7ei Ai o $,0/4.3 ecd Ad , gyp Top Bottom • Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft. •
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TOPOGRAPHIC 1 LAND SETTING: (check appropriate box) 11.DRILLING LOG •
❑Slope ❑Valley lot ❑Ride ❑ that -Tcp Bottom I I Formation Description
_ LATITUDE 35 Si' "DMS OR 3X.XXXXXXXXX DD _/ 1 '
LONGITUDE.1/ ‘ MS OR 7X.XXXXXXXXX DD / [~ -
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Latitude/longitude source: jt `rPe DI'opographic map / -° +�«r, f 4:.;,:,(location of wellmust be shown on a USGS tope map andattached to / Q P�
this form if not using GPS) '
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Owner Name /
y
Street Address fZe� �C /y r� J I_
City or Town State Zip Code ' J
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Area code Phone number 12. REMARKS:
6.WELL DETAILS: s 1
a. TOTAL DEPTH: I
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ate""' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: .2 2, FT. ACCORDANCE WITH 15A NCAC 2C,,WELL CONSTRUCTION
(Use`+`if Above Top of Casing) STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.'
4d. TOP OF CASING IS I! FT.Above Land Surface3`
`Top of casing terminated at/or below land surface may require rZa4,14-.4.
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a variance in accordance with 15A NCAC 2C.0118. SI NATURERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):_ IcTHOD F TEST /; TONY R DAVIS ( '1
f. DISINFECTION:Type[ _. g/dueAmount /6, G/Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processinfg, Form GW•1a
1617 Mali Service Center, Raleigh,NC 27899.161, Phone :[phone] I Rev,2/09
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