GW1-2021-00955_Well Construction - GW1_20210404

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_ RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2314A P
1.WELL CONTRACTOR: � ��/ p. WATER B Bottom(depth):L REGISTER TO Top Bottom
Well Contractor(individual)Name pd Top Bottom Top Bottom
REGISTER WELL CO.. INC. Ai'� 2021 Top Bottom Top Bottom
Well Contractor Company Name Up1)t :
.rCHARITY orrft3t3On Processing;gctinn
; 7. CASING: Depth Diameter Thickness/
Material
Street Address LJV V I
Top 0 Bottom 236 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 R!,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 ff : Top 236 Bottom 256 Ff? in. .016 in. PVC
DATE DRILLED 03/04/2021 : Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM❑
4.WELL LOCATION: 10.,SANDlGRAVEL PACK:
Depth Size Material
CITY: WARSAW COUNTY DUPLIN Top 230 Bottom 256 Ft.#2 GRAVEL
WILMINGTON 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 fjFlat ❑Ridge ❑Other .
11.'�DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.983074 DD : 0 /13 CLAY
LONGITUDE 78 o_' "DMS OR W77.180537 DD 13 /16 SAND
Latitude/longitude source: MPS aopographic map 16 /25 SHELL BED (HOLE)
(location of well must be shown on a USGS topo map andattached to 25 /37 SAND CLAY
this form if not using GPS) 37 /52 SAND
52 /65 CLAY
5.WELL OWNER 65 /113 SAND(MED)
HEATHER BRASWELL 113 /115 ROCK(2)
Owner Name 115 /152 SAND
280 WILMINGTON RD 152 /154 CLAY
Street Address 154 /185 SAND(MED)
WARSAW NC 28398 185 /187 CLAY
City or Town State Zip Code 187 /197 SAND(COURSE)
9t 10 ) 379-4420 197 /221 CLAY
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:256
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 9(
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 49 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'W'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PIRAVIDED 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 yav;e� .� 4/05/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED VVELLACONTRACTOR 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
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