GW1-2021-00546_Well Construction - GW1_20210219

REEVE
�- NONRESIDENTIAL WELL CONSTRUCTION RECORD t ttj ] A 2021
North Carolina Department of Environment and Natural Resources-Division of Water Quality
Information Processing Unit
�`•aY � �' WELL CONTRACTOR CERTIFICATION# 2314A 9
DWR Section
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. YIELD(gpm): 50 METHOD OF TEST AIR
Well Contractor Company Name
721 WEST CHARITY ROAD f. DISINFECTION:Type HTH Amount 'IC)7
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
9t 10 289-3175 ;Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 54 Ft.— .40 PVC
_ _ ____ _ -_ ._—- _
p 04 J Ft. 4 40 PVC
---- - ---- — -_ --;To 74 Bottom 1
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID#(if applicable) :Top 111 Bottom 116 Ft. 4 .40 PVC
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ : 8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 0 Bottom 20 Ft. HOLE PLUG POURED
Irrigation[!Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 02/08/21 ;Top Bottom Ft.
4.WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
RAWHIDE :Top 54 Bottom 74 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top 104 Bottom I'll_Ft. 4 in. 016 in. PVC
CITY: NEWTON GROVE COUNTY SAMPSON Top 116 Bottom 129 Ft. 4 n. .016 in. PVC
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE .35 "DMs OR N35.217253 DD Depth Size Material
Top 0 Bottom 50 Ft. #2 GRAVEL
LONGITUDE 78 "DMS OR W78.305749 DD
— Top Bottom Ft.
Latitude/longitude source: V3PS Dropographic 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
5.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
WF PARTNFRRHIP _0 / 10 _CLAY
Facility Name Facility ID#(if applicable) 10 1 23 SAND
23 / 43 CLAY
_----Street-Address-- —— - - - _ _ _ -_ _ __, 43 --/ 53_ -- _.SAND&CLAY
-.
53 / 74 SAND(MED)
City or Town State Zip Code 74 1 103 CLAY
GFRALD WARREN 103 / 112 SAND(MED)
Contact Name 112 / 116 CLAY
PO RM 2211 116 / 129 SAND (MED)
Mailing Address 129 / CLAY
NEWTON t' ROVF Nt': 28366 /
City or Town State Zip Code : 12.REMARKS:
t 910 _385-5094
Area code Phone number
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
I SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 129 REC HAS B77,
ROD TO T WELL OWNER.
I 1
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW DATE 02
SIGNATURE OF CERTIFIED W 'L CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing:_10 FT. DAV I D L. R I T R
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Rev.2/09
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone]