GW1-2021-00478_Well Construction - GW1_20210210

�a �SrATjo�
{ NONRESIDENTIAL WELL CONSTRUCTION RECORD
_ North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: :d. TOP OF CASING IS 1.5 FT.Above Land Surface*
DAVID L REGISTER 'Top of casing terminated at/or below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO.. INC. :e. HELD(gpm); 35 METHOD OF TEST AIR
Well Contractor Company Name 721 WEST CHARITY ROAD :f. DISINFECTION:Type HTH Amount d 07
Street Address :g. WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
9( 10 ) 289-3175 :Top Bottom Top Bottom
Area code Phone number Thicknesd
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :TopQ_Bottom 225 Ft. 4 .40 PVC
OTHER ASSOCIATED PERMIT#(R applicable) :Top Bottom Ft.
SITE WELL ID#(if applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ :8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 0 Bottoml0_Ft. HOLE PLUG POURED
Imigation(Ir Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 1/13/21 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
HWY 50 :Top 225 Bottom 255 Ft. 4 n. .016 In. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) :Top BOttOm FL_in. In.
CITY: KENANSVILLE oouNTYDUPLIN :Top Bottom Ft_in. _ in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[)Slope ❑Valley dFlat []Ridge []Other : 10.SAND/GRAVEL PACK:
LATITUDE ' "DIMS OR N34.904903 DO Depth size Material
— :Top 220 Bottom 255 Ft. #2 _ GRAVEL
LONGITUDE 77 "DMS OR W77.935771 DD :Top Bottom Ft.
Latitude/longitude source: V3PS Oropographic map ;Top Bottom ft
(location of well must be shown on a USGS topo map andaffached to
this to=if not using GPS) 11.DRILLING LOG
S.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
Q_/ 4 SAND& CLAY
Facility Name Facility ID#(if applicable) CLAY
62_/ 72 SAND
Street Address 72 196 ROCK SAND LAYERS
City or Town State Zip Code CLAY
112 / 113 ROCK 8"
MFI ROSTIC 113 / 137 SAND (MED)
Contact Name n 137 / 139 ROCK(20"HARD)
190O R n0gsm CHI IRCH RnAQ : 139 / 149 SAND (MED)
Mailing Address 11 149 / 165 ROCK AND LAYERS(MED1
MAGNni IA N ay 165 1172 SAND
City or Town Stat Zip Code
12.REMARKS:
( 9108 296-6203
Area code Phone number
6.WELL DETAILS: :I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COW OF THIS
a. TOTAL DEPTH: 2.55 R HAS BEE IPROVIO DT0 T)f WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO G/ /3/21
2:SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
C. WATER LEVEL Below Top ofCasing: 41 FT. DAVID L. RFrISTFR
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form GW-1b
Y P ty- Information Processing,1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] Rev.2ro9