GW1-2021-00480_Well Construction - GW1_20210210

�- 1 r ON RESIDENTL4L 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 allor below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO., INC. :9. YIELD(gpm): 35 METHOD OF TEST AIR
Well Contractor Company Name :(, DISINFECTION:TypeJ-ITH
721 WEST CHARITY ROAD -
Amount d 07
Street Address : g• WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State Zip Code m:Top Botto Top Bottom
9( 10 ) 289-3175 Top Bottom Top_ Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Topes_Bottom 225 FLU .40 PVC
OTHER ASSOCIATED PERMIT#(B applicable) :Top Bottom FL
SITE WELL ID#('d applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring D MuniclpaltPublic❑ : S. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural D Recovery[] Injection❑ :Top 0 Bottom20 Ft. HOLE PLUG POURED
Irrigation0r Other[] (list use) Top Bottom FL
DATE DRILLED 1/12/21 ;Top Bottom Ft.
4.WELL LOCATION: ;8. SCREEN: Depth Diameter Slot Sim Material
HWY 50 :Top225_Bottom 255 FIL 4 n. —gain. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Pamel,Zip Code) :TOp Bottom—F4_In. _ in.
CITY: KENANSVILLE COUNTY DUPLIN Top Bottom FLin. _ in.
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Slope []Valley Flat ❑Ridge []Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMS OR N34.904827 DO Depth Size Material
LONGITUDE 77 Top220_Bottom 255 Ft.#_ GRAVEL
"DMS OR W77.935783 DO :Top Bottom Ft.
LatitudeAongitude source: IJ3PS Ofopographic 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
S.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
0 14 SAND&CLAY
Facility Name Facility ID#(H applicable) 4 _/ 52 CLAY
2 /72 SAND
Street Address 72 1 98 ROCK SAND LAYERS
6 1 112 CLAY
City or Town State Zip Code 112 / 113 ROCK 8"
MEL RDSTIC 113 J 137 SAND(MED)
Contact Name 137 / 139 ROCK 20" HARD
1200 S DDRSnN CHl IRrH ROAD y��/ 149 SAND WED)
7V e" m:
Mailing Address 149 / 185 ROCK SAND LAYERS(MED)
MAGN01 IA NC 28AS
1G3`—/ 172 SAND (MED)
City or Town State a 12.RE11111ARKS:
( Q108 G6-6 0
Area code Phone number `;•:.
S.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
a. TOTAL DEPTH:255 RE HAS SE(�Jy PRo ED To WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO L� U.yrr.C- �
SIGNATURE OF CERTIFIED W L C2[ ONTRACTOR y DATE
c. WATER LEVEL Below Top of Casing: 41 _FT. DAVID . R I ST R
(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, Rev.2009
1617 Mail Service Center, Raleigh, NC 2 7699-1 61, Phone : [phone]