GW1--03370_Well Construction - GW1_20240610

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: /.i �\�,i RESIDENTIAL WELL STRLCTIONCON RECORD
r- ' i Divisior.of Water Quality
\.�,�,, North Carolina Department of Environment and Natural R:sources
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44.r.r. WELL CONTRACTOR CERTIFICATION#_ 2 —5�9, — /4
1.WELL CONTRACTOR: g. T ZONES(d t
17
TONY R DAVIS Top Bottom .5 Top Bottom
Welt Contractor(individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top --Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7, CASI 2Depth Diameter Weight Material
Street Address Top Bottom L/ Ft. L4 1 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
( 704.) 276-3434
Area code Phone number 8. GRQUT: Depth Mate±ia! Method
2.WELL INFORMATION: Top O Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMITft,24_ Q ( 3 Top Bottom Ft.,
CTHER ASSOCIATED PERMIT*(it applicable)
Top Bottom Ft.
SITE WELL ID UCf applicable) - —� 0. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Re:3identiel Water Supply�`/�� TOP Bottom Ft. in. in. _
/ Top Bottom Ft. In, In.
DATE DRILLED' Top
I'_
Top Bottom Ft. In. In,
TIME COMPLETED , 2 f elV AM I PM •
4.WELL CATI N: a 10.SAND/GRAVEL PACK:
�f2Z F C UNTY Zte014) IC) Dept/iG Material
CITY: Top Bottom Ft. 78-M Gravel
{I a limbers �� I r Top Bottom Ft.
(” 5 t me,Numbers, munrly�ubd(�wlsi n Lot Nc.,Parcel,Zip Coder Top Bottom Ft.
TOPOGRAPHIC/LANDING: (check appropriate box) 11.DRILLING LOG
p Slope ❑Valley at 0 Rid a Other Top Bottom Formation Description
LATITUDE __J. "DMS OR 3X.XXXXXXXXX DD /
LCNGITUD " %DMS OR 7X.XXXXXXXXX DO //
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Latitude/longitude source: PS Dropographic map / r
(location of wart must be shown on a USGS topo map andattached to / . -
this form if not using GPS)
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oddas—
O nerN A( c A j y ..2 7 / Dfc-'y.a
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Street ddress /
C� r��?z u EGGS, NC 2 l_
City or Town State Zip Code /
Area code Phone number 12. REMARKS:
6,WELL DETAILS: bit"
a. TOTAL DEPTH: V —
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I DO HEREB"CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NC.AC 2C,WELL CONSTRUCTION
(Use'+'if Above Tr of Casing) STANDARDS,AND THAT A COP`!OF THIS RECORD HAS BEEN
PROV D • TO THE WELL OWNER.
d. TOP OF CASING IS 4 r FT.Above Land Surfaces ( ,��
'Top of casing terminated actor below land surface may require � ! A. e)(�(,4J_a
a variance in accordance with 15P,NCAC 2C 0118. SIvNATURE RTIFIED W L CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST TONY R DAVIS
f. DISINFECTION:Typeeeiraila94, Amount /t'cZ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-la
Rc... 2�09
1617 Man Service Center,76leigk,U'C�'r��i•165,ghoae.(Slit)SOTA300