GW1--03369_Well Construction - GW1_20240610

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Iy�/L 4., BESr1E vi-LL4L V4'ELL CONSTRtiC'TIO�I RECORD
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`5 ' _ r North Carolina Department of Environment and Natural Resources-DivCisio/n of Water
Quality
�. � WELL CONTRACTOR CERTIFICATION
g, ZONES(d t,):
TONY R DAVIS
1.WELL CONTRACTOR: Top—��Bottom Top _ Bottom
Bottom
VJell Contractor(Individual)Name Top —Bottom_ Top
Top —_Bottom _ Top _Bottom
DAVIS WELL BORING Thickness!
Wet Contractor Company Name
1481 LARR Diameter Weight Material Y DAVIS ROAD 7. CASI G• Depth �,e 1 • Cement
Street Address • Top Bottom..Ft. .
LAWNDALE NC 28090 _ Top Bottom Ft. _ -------
City or Town State Zip Code Top Bottom Ft. -
704 j 276-3434 8. GROUT: Depth Material Method
Area code Phone numberQ 20 Ft. Concrete Truck
2.WELL INFORMATION: 2� � `r,(, ,Y J 20 Top —
Top Bottom Bottom Ft.
,
WELL CONSTRUCTION PERMIT# Top Bottom Ft OTHER ASSOCIATED PERMIT#(H applicable)
SITE WELL ID#fi!applicable) ' 9. SCREEN: Depth Diameter Slot Size Material
Top _Bottom Ft. in. In.
3.WELL USE(Check A sicable Box): Resident Water Supply C Top Bottom Ft. In. In.
DATE DRILLED Top Bottom Ft. in. _ in. _
TIME COMPLETED AM 0 PPd/t--^'•""'
10,SAND/GRAVEL PACK:
4.WELL LN• I�, j t, /� Dapttt $ize Matetie{
CITY: COUNT`.' �V a Top) Bottom Ft. 78-M Gravel
r 2 �(Q//ode4"
Top Bottom Ft.
iltig *lt Lit No.,Parcel,Z To Bottom Ft.;��,N tubers,Co�ltm r. ,Subdivision. PP
TOPOGRAPHIC I LAND S ING: (chins•,appropria`e box) 11. DRILLING LOG
❑Slope QVasley CRidge °Other Top Bottom Formation Description
•
LATITUDE "CMS OR 3x.XXxxxXXXX DO /
MS OR 7X.XXXXXXXXX DD /
LONGITUDE ._ /
Latitude/longitude source: S [Topographic map / �-- _ ` !-.•
aocation of well must be shown on a USGS topo map andattached to I _ �. `,.
this form If not using GP5) /
ELL OWNER i
rifler
a �es 7 /
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•,,
a 1140
IQ Addre sI, _le
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M (,�
Cityor own State Zip Code
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Area code Phone number 12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:
—
b. DOES WELL REPLACE EXISTING WELL? YES D. NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
_���)s ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
c. WATER LEVEL Below Top of Casing — STANDARDS,AND THATF,COPY OF THIS RECORD HAS BEEN
(Use•+•if Aboveop of Casing) PROVIDED THE WELL OWNER.
d. TOP OF CASING IS if FT.Above Land Surface' �, r]�, r [�r 2 9
'Top of casing terminated at/or below land surface may require CI r-
a variance in accordance with 15A NCAC 2C.011 B. SIG ATURE OF FIED WELL CONTRACTOR DATE
e. YIELD(gpm): 5 J� .,,q �� �
METHO OF TEST_ TONY R DAVIS
f. DISINFECTION:Type4L.v flh'N�Amount A___CL ' PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form.Z C-la
1617 Mail Service Center, Raleigh,NC 27699-161,Phone : [phone]