GW1-2021-00953_Well Construction - GW1_20210404

RESIDENTIAL WELL.CONSTRUCTION RECORD `}1
- North Carolina Department of Environment and Natural Resources-Division of Water Quali4P tR 2021
WELL CONTRACTOR CERTIFICATION# 2314A Irf^nr.3tion procevsing Unit
I DVVR Section
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 Thickness/
721 WEST CHARITY ROAD 7. CASING: Depth ;Diameter weight Material
Street Address Top 0 Bottom 260 FLA .40 PVC
ROSE HILL NC 28458 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft:
910 289-3175
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 FLIHOLE PLUG POURED
WELL CONSTRUCTION PERMIT# Top Bottom Ft.'
OTHER ASSOCIATED PERMIT#(ff applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top 260 Bottom 280 Ft 4 in. .016 in. PVC
DATE DRILLED 03/03/2021 Top Bottom Ft.' in. in.
TIME COMPLETED AM O PM❑ Top Bottom Ft. in. in.
4.WELL LOCATION: 10.'SAND/GRAVEL PACK:
Depth Size Material
CITY: WARSAW COUNTY DUPLIN Top 255 Bottom 280 Ft.#2 GRAVEL
845 VEECHES MILL RD Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top BOttOm Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley @(Flat ❑Ridge ❑Other 11.!DRILLING LOG
LATITUDE 35 o Top Bottom Formation Description
•DMS OR N35.053826 DD 255 /290 SAND(COURSE)
LONGITUDE 77 1 "DMS OR W77.99343-9 DD /
Latitude/longitude source: @f-'PS Dropographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) /
6.WELL OWNER /
RON ROBINSON /
Owner Name /
859 VEECHES MILL RD /
i
Street Address
WARSAW NC 28398 /
City or Town State Zip Code /
9( 10 ) 935-0967 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:280
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO @f
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 36 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PRO IDED TO THE WELL OWNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require f
, 4/05/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 45 METHOD OF TEST AIR DAVID L REGISTER k
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 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Rev.2/09
i ';