GW1--03371_Well Construction - GW1_20240610

`:,, ; ti7, RESIDENTIAL WELL CONSTRUCTION RECORD
it,,`� ' � North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# . ,__ ,s,3 1� /4
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1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Top_____ Na Bottom 4/Q Top _—.Bottom
Wei Contractor(Individual)Name Top __Bottom Top Bottom
DAVIS WELL BORING Top_ Bottom Top Bottom —
Weil Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter 'Weight Material
Serest Address Tcp "'f 1.Bottom5 Ft. 24 .5 Cement
LAWNDALE NC 28090 Top _Bottom Ft. _
City or Town State Zip Code Top Bottom Ft. . _ __
( 704) 276-3434 _ Material MethodArea code Phone number 8. GRCLUT: Depth
2.YVELL INFORMATION: ®�l /�
Top U Bottom 20 Ft._ Concrete Truck
WELL CONSTRUCTION PERMIT# !� Tcp —Bottom Ft.
OTHER ASSOCIATED PERMIT-Cif applicable)
Top Bottom �Ft._ ._
SITE WELL ID#Q!applicable) S. SCREEN: Depth Diameter Slot Size Material
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3.WELL USE(Check A iicable Box): Residential � Top___—Bottom Ft. in. in.
ential Water Supply� —� Y J
q• Top Bottom Ft. in. in.
DATE DRILLED Top Bottom Ft. in. in.
TIME COMPLETED , _G a _ AM 0 PM I!r''
10.SAND/GRAVEL PACK:
4.WELL LqFATf : i „y �'�' Depth $tie Material
::ITY; !A,�f � ¢ �(LIN COUNTY L f oc, ��rq Tog2O_,Boaor( _Ft. 78—M Gravel
W 4,STA e Lid .eG 1 q L Top Bottom Ft. —
(Street Name;Numbers,Community,S�1C0'n�isIon,Lot No.,Parcel,LF Code) Top Bottom Ft. __._—.
TOPOGRAPHIC I LAND- SSETTING: (check appropriate box) , DRILLING LOG
cSlope OVaiey (it�t ❑Ride ❑Other Tcp Bottom Formation Description
LATITUD .7 .DMS OR 3X.XXX O XXXX DD /
LONGITUDE - / 1DMS OR 7X.XXXXXXXXX DD -/ —
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Latitude/longitude source: [�I�opo9�Phic map f
(location of well must be shown on a USGS tops map anda'tecned to _ / -
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this form if not using GPS J} / :�l..L.' L1 .
5.WELL.OWNERA , oJui f4g7 - t 1UN 1 O lOZl _ .
ner Name /-- �,{prttte tP<r..n
1 11 B41,y .E3 72 IRAir - , S; ,ur4
Ltfj!drag! 1J7 P A) C 2$09Z
City or Town State Zip Code /_
Area code Phone number 12. REMARKS: •
6.WELL DETAILS: 5 f
—
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES C NO iI.,+••••''' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
( Above
c, WATER LEVEL BelowTop of Casing STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
Use'+'if Top of Casing} PROVI ED TO THE WELL OWNER. !
d. TOP OF CASING IS 4 1 -FT.Above Land Surface' t:) 41l .__
'fop of casing terminated at/or below land surface may require Yfr• , /�-'r ` T
a variance in accordance with 15A NCAC 2C.0118. GNATURE RTr IED WELL CONTRACTOR DATE
a. YIELD(gpm):_ METHOD OF'TEST TONY R DAVIS
f. DISINFECTION:Type Amount A V G Zr PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-la
1617 Mal Service Center,Raleigh, NC 27699-161,Phone : [phone] Rev:2/09