GW1-2021-07589_Well Construction - GW1_20210903

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r - RESIDENTIAL 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 180 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 Top 180 Bottom 220 Ft.2 in. .016 in. PVC
DATE DRILLED 02/1/2021 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 PENDER Top 175 Bottom 220 Ft.#1 GRAVEL
1006 MALLARD ROOST DR Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley (,(Fiat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.655264 DD 156 /180 ROCK/CLAY LAYERS
LONGITUDE 77 "DMS OR W77.904388 DD 180 /203 SAND(FINE)
Latitudellongitude source: RIPS Dropographic map 203 /205 ROCK
(location of well must be shown on a USGS topo map andattached to 205 /222 SAND(FINE)
this form if not using GPS) 222 /240 CLAY
S.WELL OWNER Vj
RANDALL PUGH /
Owner Name /
----- --006-MALLARD ROOST DE
Street Address —
/ p(0
BURGAW NC 28425 / 1 O pWR
City or Town State Zip Code /
9( 10 ) 540-6674 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:220
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: 3 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'Y'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROV 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 f 5/10/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WEJKCONTRACTOR DATE
e. YIELD(gpm): 25 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 GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09