GW1-2021-00959_Well Construction - GW1_20210404

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� �RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality APR ,� 4 202i
WELL CONTRACTOR CERTIFICATION# 2314A ' linfbi natn?n Processing Unit
DWR 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 Ft�4 .40 PVC
ROSE HILL NC 28458 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft,
9t 10 ) 289-3175
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Fti HOLE PLUG POURED
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMIT#(it 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 N( : Top 260 Bottom 280 Ft 4 in. .016 in. PVC
DATE DRILLED 03/03/2021 : Top Bottom Ft in. in.
Top Bottom Ft: in. in.
TIME COMPLETED AM❑ PM❑
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
Top Bottom Formation Description
LATITUDE 35 "DMSOR N35.053826 DD 0 /4 SAND
LONGITUDE 77 "DMS OR W77.99343-8 DD 4 /9 CLAY
Latitude/longitude source: Rf;PS Elropographic map 9 /14 SAND CLAY MIX
(location of well must be shown on a USGS topo map andattached to 14 /23 CLAY
this form if not using GPS) 23 /56 SAND COURSE
6.WELL OWNER 56 /65 CLAY
RON ROBINSON 65 /83 SAND CLAY LAYERS
83 /100 SAND WED)
Owner Name 100 /101 ROCK 0"THICK)
859 VEECHES MILL RD 101 /138 SAND CLAY LAYERS (MED)
Street Address 138 /201 SAND(COURSE)
WARSAW NC 28398 201 /213 CLAY
City or Town State zip Code 21.3 /217 ROCK CLAY LAYERS
9t 10 ) 935-0967 217 /255 CLAY
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:280
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO d
II 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 ED 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 �� `t 4/05/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED ELL CONTRACTOR DATE
e. YIELD(gpm): 45 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 GWAa
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09
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