GW1--03477_Well Construction - GW1_20240611

,< ; Ftr:v. , Ct-\ RESIDEArTL4L «'ELL CONSTRUCTION RECORD
�„�\,�_ / North Carolina Department of Environment and Natural Resources.Divisions of Water Quality
�ssZt Wit' WELL CONTRACTOR CERTIFICATION# .—' &... �7 6 "
1.WELL CONTRACTOR: g. W TER ZONES c . ;1j'
ir
TONY R DAVIS Top JL7_Bcttom, Top Bottom
Weil Contractor(Individual)Name lop Bottom ___ Top_ Bottomy—_
DAVIS WELL BORING Top Bottom Top Bottoms
Wet Contractor Company Name --
14$1 LARRY DAVIS ROAD 7. CA•5i G• I Thickness/
Dept J Diameter Weight Material
Street Address Top Botta Ft.— 24 1 .5 Cement
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code
704) 276-3434 Top Bottom Ft.
Area code Phone number 8. GROOUT: Depth Material Method
2.WELL INFORMATION: Top_ Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT 3 (,aej Top Bottom Ft. ___
OTHER ASSOCIATED PERMIT#(If applicable) Top Bottom Ft.
SITE WELL ID#(ri applicable) ' 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check ApplicableBox): Residential Water Supply 0 Top_ _Bottom Ft .In. In. _
DATE DRILLED w7 `�4 " y Top Bottom Ft. In. in,
TIME COMPLETED __ AM❑ Pp ,.,--... Top Bottom Ft. in. in.
4.WEL LOCA ON: 10.SAND/GRAVEL PACK:
J Depth Size Material
CITY: OLU /�b v,g CO NTY '0 Topa, Bottonrr7 Ft.�78-M Gravel
.1/ 4Ji2L,L., Top Bottom Ft.�,
(Str_Narfie.Ndm m malty,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (chock appropriate box) .
DSlope CV ❑Flat 0 Ridge °Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE - . .""Z' O"DMS OR 3X.X CXXXXXxX DD /
LONGITUDE '�.�G. 3.7VgMS OR 7X.XXXXXXXXX DO /
Latitude/longltude source: DTo oographic map / r- _ _
+ncat/on of well must be s own on a USGS t000 map andettached to _ '.. �.
,1 L
this fcrm If not using GPS,) / �� ..:-.,;,„1:-
.- t.• •�L_ 1,'.
S.WE LOWN R / iiN1 i 1 .):j2i
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f Ow Nam El /� / Yrd!ICr��;; :i.
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reet Ad ress `�
G4oMbu3 Ai C /
City or Town State Zip Code ' /
C_____) /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO i'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: /0 FT• ACCORDANCE WITH 1.5A.NCAC 2C,WELL CONSTRUCTION
(Use`+'if Above T of asing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDE TO THE WELL OWNER.
d. TOP OF CASING IS_ FT.Above Land Surface' 7")(.24.L_ 4 ,
/�
'Top of casing terminate at/or below land surface may require �f• F. ry9,
a variance in a ante with 15A NCAC 2C.0118, SI-NATU E TIFIED.WELL NTRACTOR DATE rG,
e. YIELD(gpm):.. METHOD F TEST / TONY R DAVIS
f. DISINFECTION:Ty ount /4 6 Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information ProaessIc g,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone :[phone] Rev,Z1C9
Rev. C9