GW1-2021-00958_Well Construction - GW1_20210404

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RECEIVED
1 r ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Qualit}A tC R X 4 2021
•� M�• WELL CONTRACTOR CERTIFICATION# 2314A
ataan processing Unit
DWR Secti
1.WELL CONTRACTOR: on
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): 35 METHOD OF TEST AIR
Well Contractor Company Name 721 WEST CHARITY ROAD :f. DISINFECTION:Type HTH Amount 4 nZ
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 1 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
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 150 Ft. 4 40 PVC
OTHER ASSOCIATED PERMIT#(ff applicable) ;Top Bottom Ft.
SITE WELL ID#(ff applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ : 8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 0 Bottom 2_Ft.!HOLE PLUG POURED
Irrigation/(Other❑ (list use) Top Bottom Ft.
DATE DRILLED 02-15-21 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
PENDERLEA-BURGAW HIGHWAY :Top 150 Bottom 180 Ft. '4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. In. in.
CITY: WALLACE COUNTY DUPLIN ;Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
[]Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMs oR N34.612543 DD Depth Size Material
LONGITUDE 78 ° :Top 145 Bottom 180 Ft.;#2 GRAVEL
"DMS OR W78.010365 DD :Top Bottom Ft.
Latitude/longitude source: MPS (]Topographic 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
155 / 171 SAND(MED)
Facility Name Facility ID#(if applicable) 171 / 190 SAND CLAY MIX (MED)
Street Address /
City or Town State Zip Code /
_SHAWN WEI l S /
Contact Name /
598n PENDERI FA HWY /
Mailing Address /
WATHA NG 28478 /
City or Town State Zip Code : 12.REMARKS:
( 910.8 _231-0500
Area code Phone number
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL,WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC WC,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH:_ 180 RECO50 JAB BEEN PROM D TO THE ELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI ,
SI NATURE OF CERTIFIED W CONTRACTOR �1 DA E
c. WATER LEVEL Below Top of Casing: 35 FT. :AVID L. REGISTERi
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit within 30 days of completion to: Division of Water Quality- Information Processing, Rev /2 os-1b
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone]