GW1-2021-07588_Well Construction - GW1_20210903

�doa STATF o
' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 23I4A
1.WELL CONTRACTOR: ``O�O g. WATER ZONES(depth).
DAVI L REGISTER ®�`� V : Top Bottom Top Bottom
Well Contractor(Individual)Name 4�1 Top Bottom Top Bottom
REGISTER W LL CO., JCk Top Bottom Top Bottom
Well Contractor Company Name �gS�r Thickness/
7Stree WEST
ddr ssCHARITY RO ®` 0 cUOr :11 TopO7. CASING: Depth B ttom 180 Ft:2Diameter terial
Oeight PVC
ROSE HILL ` NC 28458 Top Bottom Ft.
City or Town State Zip Code
Top Bottom Ft.
9t 10 ) 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#('rf applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply(r Top 180 Bottom 220 Ft.2 in. .016 in. PVC
DATE DRILLED 02/1/2021 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: WILLARD COUNTY PENDER Top 175 Bottom 220 Ft.#1 GRAVEL
1006 MALLARD ROOST DR Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley fitFlat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 34
"DMS OR N34.655264 DID : 0 /10 SAND
LONGITUDE 77 "DMS OR W77.904388 DD 10 /12 ROCK
Latitude/lon itudesource: 12 /34 SAND
g (�PS �fopographic map(location of well must be shown on a USGS topo map andattached to 34 /35 ROCK
this form if not using GPS) 35 /55 SAND/ROCK LAYERS
6.WELL OWNER 55 /65 CLAY
RANDALL PUGH 65 /83 SAND/CLAY
83 [97 CLAY
Owner Name 97 /get ROCK
-1006-MAL-LARD ROOST DE — gg /119--- — — -SAND—
Street Address 119 /136 ROCK/SAND LAYERS
BURGAW NC 28425 136 /145 CLAY
City or Town State Zip Code 145 /147 ROCK
9( 10 ) 540-6674 147 /156 SAND ROCK LAYERS
Area code Phone number 12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:220
b. DOES WELL REPLACE EXISTING WELL? YES Of NO❑
I DO HEREBY CERTIFY THAT;iTHIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 3 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 D TO T E W L OWNER.
d. TOP OF CASING Is 1.5 FT.Above Land Surface"
"Top of casing terminated at/or below land surface may require Q,` , 4 5/10/21
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED W CONTRACTOR 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