GW1-2021-00481_Well Construction - GW1_20210210

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3 NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
ww 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 atlor below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO.. INC. e. YIELD(gpm):-15 METHOD OF TEST AIR
Well Contractor Company Name 721 WEST CHARITY ROAD :}, DISINFECTION:Typal-iTH Amount a 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 Thickness!
2.WELL INFORMATION: T. CASING: Depth Diameter Weight Materiel
WELL CONSTRUCTION PERMIT# :Top_Q _Bottom 225 Ft 4 .40 PVC
OTHER ASSOCIATED PERMIT#(a applicable) :Top Bottom FL
SITE WELL ID*(If applimble) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ '8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top-Q_Bottom,2,LL Ft HOLE PLUG POURED
Irrigabonfl(Other 0 (list use) :Top Bottom FL
DATE DRILLED 1/12/21 ;Top Bottom FL
1.WELL LOCATION: ;9. SCREEN: Depth Diameter Slot SW Material
HWY 50 Top 225 Bottom 255 Ft__4__in. .016 in. PVC
(Sheet Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft._in. In.
CITY: KENANSVILLE COUNTYDUPLIN :Top Bottom Ft In. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope OValley JfFlat ❑Ridge []Other : 10.SANDIGRAVEL PACK:
LATITUDE 34 "DMS OR N34.904827 pp Depth Size Material
Top 220 Bottom 255 Ft#_ GRAVEL
LONGITUDE 77 "DMS OR W77.935783 DO :Top Bottom Ft.
Latitudellongitude source: W3PS ❑topographic map ;Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this forth if not using GPS) : 11.DRILLING LOG
8.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
172 / 173 ROCK 8"
Facility Name Facility ID*(if applicable) 173 / 185 SAND(FINE)
185 / 210 CLAY
Street Address 210 / 213 BOCK
213 / 243 SAND(MED)
City or Town State Zip Code 243 1245 ROCK 16"
MFI RnSTIC 245 / 255 SAND
Contact Name 255 CLAY
1900 S DnRRON CHURCH ROAD /
Mailing Address /
j�1ao /
City or Town State Zipr "
12.REMARKS:
( 9108 296-620.1
Area code Phone number
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B.WELL DETAILS: )fJ�FIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COW OF THIS
a. TOTAL DEPTH: 955 RAS BE PRO DTO WELL OWNER.
L�,.�„i c �[FYl /39
b. DOES WELL REPLACE EXISTING WELLS YES❑ NO I� 121
: SIGNATURE OF CERTIFIED L CONTRACTOR DATE
e. WATER LEVEL Below Top ofCasing: 41 FT. DAVID I R I T R
(Use'+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
s of completion to: Division of Water Quality Fenn
y p ty - Information Processing, Rev. 109 GW
Submit within 30 days
1617 Mail Service Center, Raleigh,NC 27699-161,Phone: [phone]