GW1-2021-04206_Well Construction - GW1_20210827

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RESIDENTL4L WELL CONSTRUCTION RECORD AUG 2 7 2021
North Carolina Department of Environment and Natural Resources-Division of Water Quality jrforr', 000 Proccul Si'`g Un t
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..... WELL CONTRACTOR CERTIFICATION# 2314A
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'
9( 10 ) 289-3175
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 FtJ HOLE PLUG POURED
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
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SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box):, Residential Water Supply if 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:
CITY: PENDERLEA couNTY FENDER Depth Size Material
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 ❑Valley I(Flat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 _ "DMS OR N34.606300pDID 0 /11 CLAY
LONGITUDE•77 °_ "DMS OR W-77.988401FJ DID 11 /34 SAND
Latitude/longitude source: tws Qropographic map 34 /74 CLAY
(location of well must be shown on a USGS topo map andattached to 74 /76 SAND
this form if not using GPS) 76 /80 CLAY SAND MIX
5.WELL OWNER : 80 /82 ROCK 24"(SOFT)
RYAN PIERCE 82 /102 SAND CLAY MIX
102 /123 CLAY
Owner Name 123 /140 SAND(MED FINE)
HORSE BRANCH RD : 140 /155 ROCK SAND-LAYERS(MED/FINI
Street Address 155 /166 CLAY
PENDERLEA NC 28478 166 /168 ROCK 2"SOFT
City or Town State Zip Code 168 /178 SAND&CLAY ROCK LAYERS
9t 10 ) 247-2754 178 /220 SAND(MED)
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:230
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: 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
PROW 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 i AL41
08/23/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL MNTRACTOR DATE
e. YIELD(gpm): 50 METHOD OF TEST AIR : DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 6 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