GW1-2021-00861_Well Construction - GW1_20210404

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ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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 48 Ft.:4 .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.WELL INFORMATION: Top 0 Bottom 20 Ft1 HOLE PLUG POURED
WELL CONSTRUCTION PERMIT#2100062 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(it applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply id Top 48 Bottom 68 Ft:4 in. .016 in. PVC
DATE DRILLED 02/25/2021 : 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: KELLY COUNTY BLADEN Top 45 Bottom 68 Ft.#2 GRAVEL
1624 LIGHTWOOD KNOT 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 W(Flat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.445467 DD : 0 /18 COURSE SAND
LONGITUDE 78 o I DMS OR W78.278895 DD 18 /33 CLAY
Latitude/longitude source: gf-'PS Olopographic map 33 /70 SAND WED FINE)
(location of well must be shown on a USGS topo map andattached to 70 / ROCK
this form if not using GPS) /
5.WELL OWNER /
CLEAVON HARRELL /
Owner Name
pirm
1624 LIGHTWOOD KNOT RD / � � • - —
Street Address /
KELLY NC 28448 APR n
City or Town State Zip Code /
9� 10 ) 471-5053 / I
Area code Phone number EMIR G ,C-�ien
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:68
b. DOES WELL REPLACE EXISTING WELL? YES I( NO❑
I DO HEREBY CERTIFY THATITHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 8 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
PROADED 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 4/05/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED W&ILL CONTRACTOR DATE
e. YIELD(gpm): 45 METHOD OF TEST AIR DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 4 OZ PRINTED NAME OF PERSONi CONSTRUCTING THE WELL
I
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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