GW1-2021-00476_Well Construction - GW1_20210210

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e RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of Water Quality
Qp- WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: g. WATER ZONES(depth):
DAVID L REGISTER Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
REGISTER WELL CO.. INC. Top Bottom Top Bottom
Well Contractor Company Name
Thicknes
721 WEST CHARITY ROAD 7. CASING: Depth weights/
Dismat it weightN
Material
Street Address Top 0 Bottom 220 Ft.2 .40 PVC
ROSE HILL NC 28458 Top Bottom FL _
City or Town Sub ZIP Code Top Bottom FL
9101289-3175
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 FL HOLE PLUG POURED
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMITa(if applicable) Top Bottom Ft.
SITE WELL ID e(rt applicable) : S. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply N : Top 220 Bottom 240 Ft2 in. .016 in. PVC
DATE DRILLED 1/14/21 : Top Bottom Ft_in. _ in.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: ROSE HILL CouNTYDUPLIN Top210 Bottom240 Ft.#2 GRAVEL
BALD EAGLE LANE Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom_Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope Malley UfFlat ORidge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.795728 Do p /2 SANDY CLAY
LONGITUDE 78 "DMS OR W78.107878 DD 2 116 CLAY
Latitudenon hudesource: 16 /22 SAND
9 fi�PS Qfopogrephic map
(location of well must be shown on a USGS topo map andattached to 22 /41 SAND CLAY LAYERS
this form if not using GPS) 41 /55 CLAY
5.WELL OWNER : 55 /62 ROCK 1"THICK
JUAN & GALLARDO RIVERA : 62 /105 SAND WED)
105 /106 ROCK(4"LAYER)
Owner Name 106 /145 SAND WED)
348 HELEN ST 145 /175 CLAY SAND LAYERS
Street Address 175 /180 SAND
JACKSONVILLE NQ 28s+d6 : 180 /181 ROCK6"
City or Town Stale Zip Code 181 /191 SAND
9t 10 ) 270-4457 : 191 /192 ROCK 1"THICK
Area code Phone number
I 12. REMARKS:
S.WELL DETAILS: .• P `;-A
a. TOTAL DEPTH:240
b. DOES WELL REPLACE EXISTING WELL? YES pt N rrD JO``: 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 20 L FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN
PROV ED TO THE WELL OWNER.
d. TOP OF CASING IS 1.5 FT.Above Lend Swface°
'Top of casing terminated aVor below land surface may require q�, - y. IwJ�/ 2/3/21
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST AIR DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 4 OZ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mall Service Center, Raleigh,INC 27699-161,Phone:[phone] Rev.2/09