GW1-2021-04209_Well Construction - GW1_20210827

REC
RESIDENTL4L WELL CONSTRUCTION RECORD AUG 7 202�
S' North Carolina Department of Environment and Natural Resources-Division of water Quality sS���,3 1j►111
�`IItOin�• WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: g. WATER ZONES(depth):
DAVID L REGISTER Top Bottom 1 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 190 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 j( Top 190 Bottom 210 Ft.2 in. .016 in. PVC
DATE DRILLED 08/16/21 : 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: WILLARD COUNTY PENDER Tap 180 Bottom 210 Ft.12 GRAVEL
693 JOHNSON NURSERY 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 @(Flat ❑Ridge ❑Other : 11. DRILLING LOG
LATITUDE. 34 Top Bottom Formation Description
DMS OR N34.682451 DD" : 168 /178 SAND CLAY MIX
LONGITUDE 77 _ "DMS OR W-77.957640 DD 178 /179 ROCK 12"
Latitude/longitude source: if.-PS OTopographic map 179 /189 SAND CLAY MIX
(location of well must be shown on a USGS topo map andattached to 189 /203 SAND
this form if not using GPS) 203 /210 ROCK SAND LAYERS
6.WELL OWNER 210 /213 CLAY
TRACY PAINTER 213 /214 ROCK 6"
214 /221 SAND CLAY MIX
Owner Name — 221- -/240- CLAY -
693 JOHNSON NURSERY RD /
Street Address /
WILLARD NC 28478 /
City or Town State Zip Code /
9t 10 ) 552-5043 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:210
b. DOES WELL REPLACE EXISTING WELL? YES fill' NO❑
I DO HEREBY CERTIFY THATI�THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 51 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED 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 8/23/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CtNTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TESTAIR DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 6 OZ PRINTED NAME OF PERSON'CONSTRUCTING THE WELL
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