GW1-2021-00956_Well Construction - GW1_20210404

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RESIDENTL4L 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 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 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 id Top 236 Bottom 256 Ft.2 in. .016 in. PVC
DATE DRILLED 03/04/2021 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: 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 fifFlat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE "DMS OR N34.983074 DD : 221 /256 SAND
LONGITUDE 78 "DMS OR W77.180537 DD /
Latitudellon itude source: /g (�PS Qropographic map / e(location of well must be shown on a USGS topo map andattached toin
this form if not using GPS)
6.WELL OWNER AN
HEATHER BRASWELL /
Owner Name / WAII
PlTic
2-80 WILMINGTON RD Ir14�r ;a VI-1
Street Address /
WARSAW NC 28398 /
City or Town State Zip Code /
9( 10 ) 379-4420 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:256
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO it
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 49 FT. ACCORDANCE WITH 15A NCA'C 2C,WELL CONSTRUCTION
(Use"+°if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
P IDED T THE WELL OWNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface* �- t
`Top of casing terminated at/or below land surface may require
0 A' 4/05/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST AI R
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