GW1-2021-01651_Well Construction - GW1_20210429

a DECEIVE®
m� D
RESIDENTL4L WELL CONSTRUCTION RECORD qNR 2 9 2021
North Carolina Department of Environment and Natural.Resources-Division of Water Quality
•� �• Information PrOCeSSln9 Unit
WELL CONTRACTOR CERTIFICATION# 2314A DWR SedlOn
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 205 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 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 205 Bottom 225 Ft 4 in. .016 in. PVC
DATE DRILLED 03/09/2021 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: KENANSVILLE COUNTY DUPLIN Top 200 Bottom 225 Ft.#2 GRAVEL
1367 BLIND BRIDGE 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 RfFlat ❑Ridge ❑Other 11. DRILLING LOG
LATITUDE 34 " Top Bottom Formation Description
"DMS OR N34.887175 DD : 0 /43 SAND&CLAY
LONGITUDE 77 "DMS OR W77.988232 DD 43 /44 ROCK 4"
Latitude/longitude source: RbPS Ofopographic map 44 /61 SAND WED)
(location of well must be shown on a USGS topo map andattached to 61 /62 ROCK 8"
this form if not using GPS) 62 /65 SAND
6.WELL OWNER 65 /66 ROCK 8"
RONALD DAIL 66 /81 SAND WED)
81 /83 ROCK 20"
Owner Name 83 /96 SAND WED)
402 VENUS COURT 96 /107 CLAY
Street Address 107 /110 SANDWED)
WILMINGTON NC 28405 110 /120 SAND CLAY
City or Town State Zip Code 120 /140 SAND(MED/FINE)
9t 10 ) 395-5247 140 /151 SAND CLAY
Area'code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:225
b. DOES WELL REPLACE EXISTING WELL? YES V NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 30 FT. ACCORDANCE WITH 15A NCAC'2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PR ED TO TIDE WE OWNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require/ — 04/15/21
a variance in accordance with 15A NCAC 2C.0118. SI NATURE OF CERTIFIED W LL C NTRACTOR DATE
e. YIELD(gpm): 50 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 Procesi ing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09