GW1-2021-04208_Well Construction - GW1_20210827

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RESIDENTL4L WELL CONSTRUCTION RECORD I' q y q
North Carolina Department of Environment and Natural Resources-Division of Water Quality AU
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WELL CONTRACTOR CERTIFICATION# 2314A ^,at D'� c3,'On
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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 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#(ff applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply(� 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 El PM❑
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: WILLARD COUNTY PENDER 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 IfFlat ❑Ridge ❑Other 11. DRILLING LOG
LATITUDE 34 ° Top Bottom Formation Description
"DMS OR N34.702303 DD 0 /13 CLAY
LONGITUDE 78 "DMS OR W-78.067678 DO 13 /27 SAND
LatitudeAon itude source: 27 /34 CLAY
9 Gwn o DIGS toaphic map 34 /42 SAND CLAY MIX
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 42 /71 CLAY
71 /81 ROCK SAND LAYERS(MED)
6.WELL OWNER 81 /95 CLAY SAND MIX
WILLIE MURRAY 95 /96 ROCK 12"(SOFT)
Owner Name 96 /111 SAND(COURSE)
BAY RD 111 /121 ROCK SAND LAYERS
Street Address 121 /141 SAND CLAY MIX(FINE)
WILLARD NC 28478 141 /142 ROCK
City or Town State Zip Code 142 /177 SAND(MED COURSE)
(� 177 /180 ROCK SAND LAYERS
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:270
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
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 V 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 8/23/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CWWCTOR DATE
e. YIELD(gpm): 50 METHOD OF TEST AIR : DAVID L REGISTER
f. DISINFECTION:Type HT H Amount 4 OZ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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
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