GW1-2021-04357_Well Construction - GW1_20210429

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CEO ION# 2314A
1.WELL CONTRACTOR: 9 WATER ZONES(depth):
DAVI L REGISTER �� �9 p Bottom Top Bottom
Well Contractor(Individual)Name p OGeses. Top Bottom Top Bottom
REGISTER WELL CO., InQt S Top Bottom Top Bottom
Well Contractor Company Name `�a1C�• Q Thickness!
721 WEST CHARITY ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 271 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:WEL-L-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 Top 271 Bottom 291 Ft2 in. .016 in. PVC
DATE DRILLED 03/15/2021 : 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 265 Bottom 291 Ft.#2 GRAVEL
2951 WILLARD 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 91Flat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.707960 DD : 243 /244 ROCK 6"
LONGITUDE 78 "DMS OR W78.039859 DD 244 /263 SNAD(MED/FINE)
Latitudellongitude source: ii;PS DTopographic map 263 /291 SAND (MED)
(location of well must be shown on a USGS topo map andattached to 291 / ROCK
this form if not using GPS) /
5..WELL OWNER /
BOBBY JAMES /
Owner Name
147 JAMES ANDREWS LANE /
Street Address /
TEACHEY NC 28464 /
City or Town State Zip Code /
9t 10 ) 289-0302 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:291
b. DOES WELL REPLACE EXISTING WELL? YES 51 NO❑
I DO HEREBY CERTIFYTHAT.THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 48 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVW TO THE WELL WNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface* � ����
"Top of casing terminated at/or below land surface may require """/ 5/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL C TRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST AIR : DAVID L REGISTER
f. DISINFECTION:Type_HTH Amount 3 OZ PRINTED NAME OF PERSOWCONSTRUCTING 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] I Rev.2/09
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