HomeMy WebLinkAboutWELL-03-2014-047863.TIF ` I RESIDENTIAL WELL CONSTRUCTION RECORD
' 4,,,,- North Carolina Department of Environment and Natural Resources-Division of Water Quality
��O" P �r WELL CONTRACTOR CERTIFICATION# 2 6_5 6 -n
1.WELL CONTRACTOR: g. WATER ZONES(depth):
TONY R DAVIS Top _Bottom Top Bottom_
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness)
1481 LARRY DAVIS ROAD 7. CA ING: Depth Diameter Weight Material
Street Address • Top 1Y Bottom l' Ft 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft.
( 704) 276-3434
Area code Phone number 8. GROUT: Depth Material Method
1.�
2.WELL INFORMATION: �/ Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# " 20 t� ! -0 Li 7 n vY� Top Bottom Ft
OTHER ASSOCIATED PERMIT#(ii applicable) Top .Bottom Ft.
SITE WELL ID#(d applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft in. in.
DATE DRILLED&/.. es, 16 Top Bottom Ft. in. in.
TIME COMPLETED /3 00 AM❑ PM Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Cf 7 1 Depth 78e Material
crrY; W b,� couNTY � Top�(J Bottom lid Ft. 78—M Gravel
• 61460 N 1 kc. L v (216° 1 Top Bottom Ft
(Street Name,Numbers,Community,Sub sion,Lot No.,Parcel,Zrp Code) Top Bottom Ft.
TOPOGRAPHIC/LAND ETTING: (check appropriate box)
❑Slope DValley at ❑Ridge� DOther
11. DRILLING LOG
LATITUDE _. A9 1 y"DMS OR 3X.XXXXXXXXX DD Top / Bottom Formation Description
LONGITUDt"_/O / XXXXX
"DM5 OR 7X.)000000=DD /
Latitude/longitude source: S :Topographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) /
/
5.WELL I3ue r
/
1
Owner Name
/
6ksi, Nile. 1N
-Street Ad ress
(',4 AW ioA f C 2 $�o ' / •
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS: O
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO(
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 4.33 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Tip of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP p of CASING IS w l Above surface Land Surface* I V 41___z./6,
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118. SIGNATUR CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 2 METH��OD�DiOFTEST TONY R DAVIS
f. DISINFECTION:Type rzuwo Amount�OZ.. PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-la
1617 Mail Service Center,Raleigh,NC 27699-161,Phone :(919)807-6300 Rev.2/09