GW1-2021-04203_Well Construction - GW1_20210827

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r�} t NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•av""p N' WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: : d. TOP OF CASING IS .5 FT.Above Land Surface'
DAVID L REGISTER "Top of casing terminated;aVor 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 R 07
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State `e ode :Top Bottom Top Bottom
9( 10 289-3175 � ;^y^� ;Top Bottom Top Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: °� 1. � 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top 0 Bottom 78 Ft. 4 40 PVC
��r'� '�Or :To Bottom Ft.OTHER ASSOCIATED P_ER_M_i_T#(ff applicable) _a:;�1 ��• P _ _
SITE WELL ID#(if applicable)- �P�O��"QS�`'v :Top Bottom Ft. — V --
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ :8. GROUT: Depth Material Method
Ind ustrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 0 Bottom 20 Ft. HOLE PLUG POURED
Irrigation Other❑ (list use) Top Bottom Ft.
DATE DRILLED 05/20/21 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
1155 HAWS RUN RD .Top 78 Bottom 118 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: MAPLE HILL COUNTY ONSLOW Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMS OR N34.682846 DD Depth Size Material
LONGITUDE 77 _ "DMS OR W77.563191 DD :Top�Bottom 118 Ft. GRAVEL
Top Bottom Ft.
Latitude/longitude source: VaPS Oropographic 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
0 / 15 SAND WI-SMALL CLAY LAYERS
Facility Name Facility ID#(if applicable) 155_/ 23 CLAY
23135 CLAY&SHELL
Street Address _/ 118 _LIMESTONE_ _
118 / 138 -LIMESTONE MUDDY
City or Town State Zip Code /
DANNY RAW[ S /
Contact Name /
_1155 HAWS RUN RD /
Mailing Address /
MAR F HII I NC 28454 /
City or Town State Zip Code
12.REMARKS:
( 910 389-077.
Area code Phone number
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL ONSTRUCTION STANDARDS,'AND THAT A COPY OF THIS
a. TOTAL DEPTH: 1 1 8 :ECHA�
B�E OVIDED O THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO G/ : SIGNATURE OF CER IFIED WEL ONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 9 FT. :J�gVID L. RE I TER
(Use"+^if Above Top of Casing) : PRINTED NAME OF PERSON C i NSTRUCTING THE WELL
Form GW-1b
Submit within 30 days of completion to: Division of Water Quality - Information ProcesIsing, Rev.2/09
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone]