GW1--04052_Well Construction - GW1_20240708

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/-° RESIDE.'�TML WELL CONSTRUCTION RECORD
V.. iLi, .7.1North Carolina Departtrent of Environment and Natural Resources-Division of Water Quality
NI`"": `ter` WELL CONTRACTOR CERTIFICATION# 2(y-.54 `j
1.WELL CONTRACTOR: 9. A E ONES(de
TONY R DAVIS Top Bottom -y- Top Bottom
Well Contractor(Individual)Name Top Bottom ,,—,_-_ Top Bottom
DAVIS WELL BORING Top —Bottom ____ Tops Bottom
Wet Contractor Company Name ••
77riekness!
1481 LARRY DAVIS ROAD 7. CAS : Depth �/ Diameter Weight Material
Street Address • To Botton{� T Ft. `4 1.5 Cement
LAWNDALE NC 28090 Top _ Bottom -Ft.
City or Towr. State Zip Code Too Bottom Ft.
( 704) 276-3434 `--
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: +� /� Top of Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMT L_5 n
# 4/0 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#Crapplicable) Top Bottom Ft
SITE WELL ID Skit applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Resident alWater Supply V Top Bottom _Ft. .in. in.
DATE DRILLED 1112' Top Bottom Ft in. —� in. —
Top Bbttom Ft in. in,
TIME COMPLETEDPM . —
4.WELL LOCATIO /? AM 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: '13NTf#P0 di ToaO Bottom G� Ft., 78—M Gravel
12`
�, y �A r Top Bottom Ft.
Streat Na e,Numbers, orn un y, bdivi;Ion,Lo o_, reel,ZZ:Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
DSiope DV y El °Ridge DOther 11. DRILLING LOG •
Top Bottom Formation Description
LATITUDE _.34 S OR 3X.XXxXXXX.XX DD
LONGITUDE MS OR 7x.xxxxXXXxx DO I —
Latitude/longitude source: I it's" Gfiopographic map
(location of wed/must be shown on a USGS topo map andattached to /
this form if not using GPS) / C`A L!VEL
S.YYE NE '1
/4/4:77.
Owner Name x Q 1.22 i4,43241,6).3 y J i e _ — --I - IcA©.xse -er►4;p(lidStreet Arldr I — --- D'A C
� PLL ^ zi `--
City or Town State Zip ode /
_) /
Area code Phone number
12. REMARKS: ,
&.WELL DETAILS: tie ' A -- -a. TOTAL DEPTH: Jy(•
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 11.6FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+'if Above T p oi Casing) STANDARDS,AND THAT A COPY OF THS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER„
d. TOP OF CASING IS FT.Above Land Surface" -
'Top of casing terminate at/or below land surface may require ;//_ 4
a variance in accordance with 15A NCAC 2C.0118. SIG TURF 0 D WELL C CTO , DATE S
a. YIELD(gpm): �METTHOD OF TEST /r, TONY R DAVIS
f. DISINFECTION:Typee Amount / G CI PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW1a
1617 Mall Service Center, Raleigh, NC 27699-161, Phone :(9'9)507-6300 Rev.2/09.