GW1-2021-04173_Well Construction - GW1_20210827

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RESIDENTIAL WELL CONSTRUCTION RECORD RC E M r
' - North Carolina Department of Environment and Natural Resources-Division of Water uali
_ p Q tyAUG 2 7 2021
WELL CONTRACTOR CERTIFICATION# 2314A 1-f— ,
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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 210 Ft.'4 .40 PVC
ROSE HILL NC 28458 Top Bottom Ft.
City or Town State Zip Code
9( 10 ) 289-3175 Top Bottom Ft
Area code Phone number 8. GROUT: Depth Material Method
---2.WEL'L'INFORMATIONJ �.__—,� _ ___. ._____— -Top O Bbttom20- ----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 N( Top 210 Bottom 230 Ft 4 in. .016 in. PVC
DATE DRILLED 03/17/21 : 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: DELWAY COUNTY SAMPSON Top 205 Bottom 230 Ft.#2 GRAVEL
HWY 903 Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley GtFlat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 o "DMS OR N34.799839 DO : 0 /20 CLAY
LONGITUDE 77 "DMS OR W78.211514 DO : 20 /35 SAND
Latitude/longitude source: GAPS Oropographic map 35 /58 SAND/CLAY LAYERS
(location of well must be shown on a USGS topo map andattached to 58 /98 SAND RED)
this form if not using GPS) 98 /104 CLAY
104 /177 SAND (COURSE)
6.WELL OWNER 177 /178 8" ROCK SOFT
MARYLAND BROOKS 178 /195 SAND(COURSE)
Owner Name — 195 /208 --------SAND/MUD-MIX — --� —��
112 EAST MAGNOLIA LISBON RD ` 208 /209 ROCK 10"
Street Address 209 /235 SAND WED)
ROSE HILL NC 28458 235 /240+ SAND/MUD MIX
City or Town State Zip Code /
9( 10 ) 548-2222 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:230
b. DOES WELL REPLACE EXISTING WELL? YES 5f NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 49 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 DIED TO THE WELL OWNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface* 1�
*Top of casing terminated at/or below land surface may require �( GZt� till 4/30/19
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED W LL CONTRACTOR DATE
e. YIELD(gpm): 50 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 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09