GW1-2021-04356_Well Construction - GW1_20210429

I
STxA�
r RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR�TIFICATION# 2314A
1.WELL CONTRACTOR: ��s� g. WATER ZONES(depth):
DAVID L REGISTER Q� 11 10ti-�_xk Top Bottom Top Bottom
Well Contractor(Individual)Name ss\�9 Top Bottom Top Bottom
REGISTER WELL CO.. INC. .,.nGfl Top Bottom Top Bottom
Well Contractor Company NameThickness/
721 WEST CHARITY ROAWd O 7. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 271 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 Bottom20 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 I( Top 271 Bottom 291 Ft.2 in. .016 in. PVC
DATE DRILLED 03/15/2021 Top Bottom Ft, in. in.
TIME COMPLETED AM p PM
Top Bottom Ft. in. in.
El
4.WELL LOCATION: 10,SAND/GRAVEL PACK:
CITY: WILLARD couNTY FENDER Depth Size Material
Top 265 Bottom 291 Ft.#2 GRAVEL
2951 WILLARD 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 5tFlat ❑Ridge ❑Other ; 11.DRILLING LOG
L Top Bottom Formation Description
LATITUDE 34
"DMS OR N34.707960 DO : 0 /20 CLAY
LONGITUDE 78 "DMS OR W78.039859 DD 20 /35 ;SAND&CLAY
LatitudeAon itude source: 35 /63 CLAY
9 GdGPS Ofopographic map
(location of well must be shown on a USGS topo map andattached to 63 /64 ROCK 6"
this form if not using GPS) 64 /80 SAND&CLAY
5.WELL OWNER : 80 /83 ROCK&SAND
83 /96 SAND(MED)
BOBBY JAMES 96 /125 !ROCK&SAND(MED)
Owner Name 125 /135 ;SAND(MED)
147 JAMES ANDREWS LANE 135 /140 'SAND&CLAY
Street Address 140 /175 SAND(FINE)
TEACHEY _ _ _ NC 28464 175 /176 ROCK 12"
City or Town State Zip Code 176 /230 CLAY
9( 10 ) 289-0302 230 /243 SAND (MED/FINE)
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:291
b. DOES WELL REPLACE EXISTING WELL? YES(f NO❑
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 48 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
• .
d. TOP OF CASING IS 1.5 FT.Above Land Surface" PRO�ED TO THE WELL OWNE� t
Top of casing terminated aUor below land surface may require 15/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL GTJNTRACTOR DATE
e. YIELD(gpm): 25 METHOD OF TEST Al R
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] f Rev.2109
I
I