GW1-2021-04233_Well Construction - GW1_20210419

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- `�- RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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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 163 Ft.2 .40 PVC
ROSE HILL NC 28458 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
9r 10 ) 289-3175
Area code Phone number 8. GROUT: Depth Material Method
Top-0_—_-Bottom 20 ---FU 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 Top 163 Bottom 183 Ft:2 in. .016 in. PVC
DATE DRILLED 02/03/2021 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM❑ Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: WILLARD COUNTY PENDER Top 155 Bottom 183 Ft.#2 GRAVEL
640 OAK TREE 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 UfFlat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.694840 DD : 0 /11 SAND
LONGITUDE 77 "DMS OR W77.943276 DD 11 /15 ROCK
Latitude/longitude source: IMPS Ofopographic map 15 /41 CLAY
(location of well must be shown on a USGS topo map andattached to 41 /54 SAND CLAY MIX
this form if not using GPS) 54 /82 CLAY
S.WELL OWNER : 82 /183 SAND ROCK LAYERS
MONICA NEWTON 183 / CLAY
Owner Name
a
40 OAK TREE ROAD / nD a 9f1��
Street Address /
WILLARD NC 28478
City or Town State ZipCode
910 28t )
4-2235
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:183
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 20 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 ED TOT E WELL OWNER.
d. TOP OF CASING IS 1.6 FT.Above Land Surface'
"Top of casing terminated at/or below land surface may require 03/01/2121
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL"CONTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST AIR : DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 3 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