GW1--02685_Well Construction - GW1_20240507

!• E 1 Z"tr RESIDENTIAL WELL CONSTRUCTION RECORD
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s�, �' r North Carolina Department of Environment and Natural Resources-Division of Water Quality
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�. WELL CONTRACTOR CERTIFICATION# 9 ! I •
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1.WELL CONTRACTOR: g. WATER ONES(de
TONY R DAVIS • Top he 4Bottom ., 1 Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CAN : Depth • Diameter Weight Material
Street Address Top J� Bottom Ft. 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft. ,
City or Town State Zip Code Top Bottom Ft.
( 704) 276-3434 •
Area code Phone number 8. GROUT: "Depth Material Method
2.WELL INFORMATION: /_ y/C� Top 0 Bottom 20 Ft. Concrete Truck
_ _ WELL CONSTRUCTION PERMIT#�.V-2 /" -J . - Top - Bottom Ft.
OTHER ASSOCIATED PERMIT#(ff applicable) Top Bottom Ft. _ •
•
SITE WELL ID#(if applicable) • • 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Ap licabl Box): esi ntial Water Supply❑ Top Bottom Ft. .in. • in.
DATE DRILLED •
/^►+�' Top Bottom Ft. ` ' in. in.
TIME COMPLETED V AM❑ PM� Top Bottom Ft. in. in. •
4.WELL L ATION• 10.SAND/GRAVEL PACK: I
n t Depth Size Material
CITY: ry�d/�+ COUNTY O Top d Bottom Ft.! 78—M Gravel -
r)$ /'f e i.s A /' b� RO/ Top Bottom Ft.'
1.
(Street Name,Numbers, ommunity,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft. '
TOPOGRAPHIC/LAND Soh I ING: (check appropriate box) . •
•
❑Slope ❑Valley at ❑Ridge ID 11.DRILLING LOG
�Q •Top Bottom Formation Description
LATITUDE • / "DMS OR 3X.XXXXXXXXX DD /
LONGITUDE 2 0...e bqZ"DMS OR 7X.XXXXXX)00(DD /
Latitude/longitude source: L' 'S OTopographic map /
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) /
/ _ _
6.WELL OWNER
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V er2 1 Wit f A Owner Name I / N1AY z� if�u
eel y a �7X1 J /
Stree ress - / Irf.C:r^� - _F er; i+�':?
y4N /V / DIN Ci'3Ou
City or Town State Zip Code • /
( ) . /
Area code Phone number
• 12. REMARKS: •
6.WELL DETAILS:
a. TOTAL DEPTH: �"
• b. DOES WELL REPLACE EXISTING WELL? YES NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
f� ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
• c. WATER LEVELUse"+"Below AboveTo TOl.Gasing: -/ STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
•
(Use if Top of Casing)
PROVID 0 THE WELL OWNER.
d. TOP OF CASING IS,�� FT.Above Land Surface* ^ / � ��
*Top of casing to hinated at/or below land surface may require R �(1-C/�
a variance in^a'c'cordance with 15A NCAC 2C.0118. SI ATURE RTIFIED WELL CONTRACTOR DATE • •
e. YIELD(gpm): .. co METH.Op OF TEST • TONY R DAVIS i •
f. DISINFECTION:Type A/Ne Amount lb O . PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-la
1617 Mail Service Center,Raleigh,NC 27699-161,Phone :[phone] 1 1 Rev.2/09 •
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