GW1-2021-00548_Well Construction - GW1_20210219

E
s
dED
seSTATF4 RECEIVE:
NONRESIDENTLQL WELL CONSTRUCTION RECOI30u 19 2021
' North Carolina Department of Environment and Natural Resources-Division of Water Quality
• '^��' 2314A 11h,formation Processing Unit
WELL CONTRACTOR CERTIFICATION# I
I d DWR Section
1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.5 FT.Above Land Surface*
DAVID L REGISTER "Top of casing terminatedM/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):_35 METHOD OF TEST AIR
Well Contractor Company Name :721 WEST CHARITY ROAD f. DISINFECTION:Type HTH Amount 4 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: :7. CASING: Depth Diameter Weight Material
__--WELLGONSTRUC—TION PERMIT# ---- — - - Top 0 Bottom 52 Ft. 4�—" :40 --PVC
OTHER ASSOCIATED PERMIT#(ff applicable) :Top 72 Bottom 102 Ft. 4 .40 PVC
SITE WELL ID#(if applicable) :Top 110 Bottom 119 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
Irrigationl(Other❑ (list use) Top Bottom Ft.
DATE DRILLED 02/04/21 ;Top Bottom Ft.
4.WELL LOCATION: ; 9. SCREEN: Depth Diameter Slot Size Material
RAWHIDE RD :Top 52 Bottom 72 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top 102 Bottom 110 Ft. 4 in. 016 in. PVC
CITY: NEWTON GROVE COUNTY SAMPSON :Top 119 Bottom 131 Ft. 4 in. .016 in. PVC
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 35 "DMS OR N35.217413 DD Depth Size Material
L Top 40 Bottom 11 0 Ft.i#2 _GRAVEL
LONGITUDE 78 "DMS OR W78.305447 DD :Top Bottom Ft.
LatitudeAongitude source: BPS propographic 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
WF PARTNFRSHIP 0 / 10 CLAY
Facility Name Facility ID#(if applicable) 10 1 25 _SAND
25=141 — - -CLAY - --- - —— --- ---
1 / 52 SAND&CLAY
522_/ 72 SAND(MED)
City or Town State Zip Code 72 / 102 CLAY
GERALD WARR N 102 / 110 SAND (MED)
Contact Name 110 / 118 SLAY
PO BOX 223 : 118 /_131 SAND(MED)
Mailing Address 131 / 140+ _CLAY
NEWTON GRON/F NC: 2,9366 /
City or Town State Zip Code ; 12,REMARKS:
( 910fl _385-5094
Area code Phone number
6.WELL DETAILS: : 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 131 ; REC D S BEEN PR VIDED T THE WE OWNER.
g�.,''
02/12/2
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI � r/�
SIGNATURE OF CERTIFIED WELL C NTRACTOR DATE
i
c. WATER LEVEL Below Top of Casing: 10 FT. AVID L_ RE I T 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 /09 b
y p ty- Information Processing, Rev.2109
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone] E