GW1-2021-04204_Well Construction - GW1_20210827

`. RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOP, TIFICATION# 2314A
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1.WELL CONTRACTOR: C.
e�qq g. WATER ZONES(depth):
D � 0 Top Bottom Top Bottom
Well Contractor(Individual)Name P`\C Nr�� Top Bottom A Top Bottom
REGISTER WELL CO.. INC. v »rCCs`t\ Top Bottom Top Bottom
Well Contractor Company Name 3�,C�a Thickness/
721 WEST CHARITY ROA{�S°tom ON 7. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 190 Ft.2 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 Ft.HOLE PLUG POURED --�-
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(If 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 gf Top 190 Bottom 210 Ft.2 in. .016 in. PVC
DATE DRILLED 08/16/21 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM 0
4.WELL LOCATION: : 10.SANDIGRAVEL PACK:
CITY: WILLARD COUNTY PENDER Depth Size Material
Top 180 Bottom 210 Ft.12 GRAVEL
693 JOHNSON NURSERY RD Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box) 11.DRILLING LOG
OSlope oValley 5tFiat oRidge pother
L Top Bottom Formation Description
LATITUDE 34
"DMS OR N34.682451 DD : 0 /12 CLAY
LONGITUDE-77 "DMS OR W-77.95764IDD : 12 /16 SAND
Latitudellon itude source: 16 /19 CLAY
g G�PS Ofopographic map
(location of well must be shown on a USGS topo map andattached to 19 /35 SAND
this form if not using GPS) 35 /58 CLAY
S.WELL OWNER - 58 /87 SAND CLAY MIX
SRACY PAINTER 87 /112 CLAY
112 /117 ROCK SAND LAYERS
owner Name 117 -/132 SAND(MED)
693 JOHNSON NURSERY RD 132 /133 ROCK 10"
Street Address 133 /142 SAND(MED FINE)
WILLARD NC 28478 142 /153 ROCK SAND LAYERS
City or Town State Zip Code 153 /162 SAND(MED FINE)
(910 ) 552-5043 162 /168 ROCK SAND LAYERS
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:210
b. DOES WELL REPLACE EXISTING WELL? YES It NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 51 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PR DED 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 �G11� � 8/23/21
a variance in accordance with 15A NCAC 2C.0118. A"r,047.44
SIGNATURE OF CERTIFIE15WYX CONTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST AIR : DAVID L REGISTER
f. DISINFECTION:Type HT H Amount 6 OZ PRINTED NAME OF PERSON ONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Proce sing, Form GWAa
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Rev.2/09