GW1-2021-00479_Well Construction - GW1_20210210

NONRESIDENTL4L WELL CONSTRUCTION RECORD
_ North Carolina Department of Environment and Natural Resources-Division of Water Quality
a.; WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.S 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 :I. DISINFECTION:Type HTH Amount 4 07
721 WEST CHARITY ROAD
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
9l 10 1289-3175 :Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 225 Ft.,4 .40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) :Top Bottom FL
SITE WELL ID#(if applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipai/Public❑ : S. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery El Injection❑ :Topes_Bottom_2Q Ft. HOLE PLUG POURED
Irrigationgilif 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_In. .016 in. _PVC
(Street Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top B011om Ft._In. In.
CITY: KENANSVILLE COUNTY DUPLIN :TOP Bottom Ft._In. in.
TOPOGRAPHIC I LAND SETTING: (check appropriate bah
❑Slope Ovalley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 _' "DMS OR N34.904903 DO Depth Size Material
LONGITUDE 77 "DMS OR W77N34.90 903 O .Top 220 Bottom 255 Ft. #2 GRAVEL
-- Top Bottom Ft.
Latitudellongitude source: 6'ttPS Oropographic map ;Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) ; 11.DRILLING LOG
6.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
172 / 173 ROCK 8"
Facility Name Facility IDS(if applicable) 173 / 185 SAND FINE
,-185 210 CLAY
Street Address t 210 / 213 ROCK
213 / 243 SAND (MED)
City or Town State Zip Code 243 / 245 ROCK(16")
MFI ROSTlr 245 / 255 SAND
Contact Name 255 / CLAY
1900 S DORSON CHI IRrH ROAD
Mailing Address �: �• -° /
MArNOI IA �J t r9R'd53 n /
City or Town VOW.` Zip Cp�g p:
1\ 1. , 12.R€MARKS:
( 910,6 296-6203 F�a
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
`,, 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
q
a. TOTAL DEPTH: 255 REP RAS BEEN t\IJIROV10ED jOTHE WE OS
913121
LL_
b. DOES WELL REPLACE EXISTING WELLY YES[I NO q� : SIGNATURE(J/�) c(O/F CERTIFIED WELL NTRACTOR DATE
c. WATER LEVEL Below Top of Casing:_.41 T. DAVID I . REC+ISTER
(Use"+•if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of Completion to: Division of Water Quality - Information Processing, Form GW-1b
Rev.2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]