GW1-2021-04205_Well Construction - GW1_20210827

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RESIDENTL4L WELL CONSTRUCTION RECORD Aga 7 2021
North Carolina Department of Environment and Natural Resources-Division of Water Quality Dt114
WELL CONTRACTOR CERTIFICATION# 2314A DWR SsCZ:ort
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.2 .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 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 Wf Top 210 Bottom 230 Ft.2 in. .016 in. PVC
DATE DRILLED 07/26/21 : 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: PENDERLEA COUNTY PENDER Top 205 Bottom 230 Ft.#2 GRAVEL
HORSE BRANCH ROAD Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope OValley GfFiat ❑Ridge OOther
11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.606300 DD 220 /222 ROCK
LONGITUDE 77 o "DMS OR W-77.988406 DD 222 /230 SAND WED)
Latitude/iongitude source: MPS Oropographic map 230 /240 SAND(FINE)
(location of well must be shown on a USGS topo map andattached to 240 /245 CLAY
this form if not using GPS) 245 /255 CLAY SAND MIX
6.WELL OWNER /
RYAN PIERCE /
Owner Name /
HORSE BRANCH RD /
Street Address /
PENDERLEA NC 28478 /
City or Town State Zip Code /
9t 10 247-2754 /
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:230
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO CAI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 35 -FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED 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 �� 08/23/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL eONTRACTOR DATE
e. YIELD(gpm): 50 METHOD OF TEST AIR : DAVID L REGISTER i
f. DISINFECTION:Type HTH Amount 6 OZ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
• E
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