GW1-2021-04355_Well Construction - GW1_20210429

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RESIDENTL4L WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 23I4A
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1.WELL CONTRACTOR: g. WATER ZONES(depth):
REGISTER
Top Bottom Top Bottom
Well Contractor(Individual)Name 0�� To Bottom Top Bottom
REGISTER WELL CO.. IN Bottom Top Bottom
Well Contractor Company Name �gc°`�g Thickness/
721 WEST CHARITY ROAD V �Q�° 7. CASING: Depth Diameter Weight Material
Street Address � - ; Top O Bottom 140 Ft 2 .40 PVC
ROSE HILL NC 84�8 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 Top 140 Bottom 160 Ft:2 in. .016 in. PVC
DATE DRILLED 03/1 1/2021 Top Bottom Ft in. in.
Top Bottom Ft: in, in.
TIME COMPLETED AM❑ PM❑
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: WILLARD COUNTY PENDER Top 135 Bottom 174 Ft.#2 GRAVEL
4490 PELHAM 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 ftFlat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 34 "DMS OR N34.660300 DD 0 /13 CLAY
LONGITUDE 78 o I "DMS OR W78.033521 DD 13 /37 SAND
Latitude/longitude source: Ct3PS propographic map 37 /55 SAND&CLAY
(location of well must be shown on a USGS topo map andattached to 55 /85 CLAY
this form if not using GPS) 85 /87 ROCK&SAND
87 /103 SAND&CLAY
6.WELL OWNER 103 /113 SAND WED)
BOBBY JAMES Owner Name 113 /114 ROCK 6°
__
114 /116 SAND WED)
6391 PELHAM ROAD 116 /126 CLAY
Street Address 126 /137 ROCK, SAND&CLAY
WILLARD NC 28478 137 /160 MED SAND WITH SOME CLAY
City or Town State Zip Code 160 /174+ CLAY
9r 10 ) 443-4551 /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: 160
b. DOES WELL REPLACE EXISTING WELL? YES(if NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 31 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PRO ED TO THE WE L OWNER.
d. TOP OF CASING IS 1.5 FT.Above Land Surface* r
*Top of casing terminated at/or below land surface may require qLt - t 04l15/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL-CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TEST AIR DAVID L REGISTER
f. DISINFECTION:Type HTH Amount 3 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] i Rev.2/09
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