GW1-2021-04207_Well Construction - GW1_20210827

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.RESIDENTIAL WELL CONSTRUCTION RECORD Air �'
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' North Carolina Department of Environment and Natural Resources-Division of Water%ftatc) k yt�On
WELL CONTRACTOR CERTIFICATION# 2314A to v
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 250 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#(ff 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 if Top 250 Bottom 270 Ft:2 in. .016 in. PVC
DATE DRILLED 6/29/21 : 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: WILLARD COUNTY FENDER Top 245 Bottom 270 Ft.#2 GRAVEL
BAY 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 UfFlat ❑Ridge ❑Other 11.DRILLING LOG
L Top Bottom Formation Description
LATITUDE 34
"DMS OR N34.702303 DD : 180 /230 CLAY
LONGITUDE 78 "DMS OR W-78.067676DD 230 /240 SAND(MED COURSE)
Latitude/longitude source: IfGPS ❑Topographic map 240 /251 AND CLAY MIX(FINE)
(location of well must be shown on a USGS topo map andattached to 251 /271 SAND(MED COURSE)
this form if not using GPS) 271 /275 CLAY
5.WELL OWNER /
_WILLIE MURRAY /
Owner Name /
BAY RD /
Street Address /
WILLARD NC 28478 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:270
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO it
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 39 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 D TO THE WELL OWNE .
d. TOP OF CASING IS 1.5 FT.Above Land Surface-
*Top
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"Top of casing terminated at/or below land surface may require L.� ` 8/23/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL IFONTRACTOR 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 GWA a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09