GW1-2021-04493_Well Construction - GW1_20210429

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5 NONRESIDENTIAL WELL CONSTRUCTION RECORD
5 / North Carolina Department of Environment and Natural Resources-Division of Water Quality` Q;,, WELL CONTRAC TIFICATION# 2314A
1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.5 � FT.Above Land Surtace'
DAVID L REGISTER ` � 9 TON ,�� *Top of casing terminated at/or below land surface may require
Well Contractor(Individual)Name Q� a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO INC. P e, ;e. YIELD(gpm): 50 METHOD OF TEST AIR
Well Contractor Company Name ><Spt� �g
LV-3n\T4R f. DISINFECTION:Type HTH Amount 4 07
721 WEST CHARITY ROADZ
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 :Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
(910 289-3175 Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 66 Ft. 4 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) To p Bottom Ft.
SITE WELL ID#(if 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 20 Ft. HOLE PLUG POURED
Irrigation//(Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 03/23/21 ;Top Bottom Ft.
4.WELL LOCATION: ;9. SCREEN: Depth Diameter Slot Size Material
935 PARKERSBURG RD :Top_66 Bottom__0 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: GARLAND COUNTY SAMPSON Top Bottom Ft. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley IjFlat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMs OR N34.843702 DD Depth Size Material
LONGITUDE 78 :Top 60 Bottom 86 Ft. #2 —GRAVEL
"DMS OR W78.441437 DD :Top Bottom Ft.
Latitude/longitude source: W3PS []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
0 / 6 SAND
Facility Name Facility ID#(if applicable) 6 1 12 SLAY
12 137 SAND(COURSE)
Street Address 37 1 50 SLAY&SAND
50 167 SLAY&SAND
City or Town State Zip Code 67 183 SAND(COURSE)
WFSI FY MFI VIN _83 / 105 CLAY&SAND
Contact Name 105 / 115 SAND(FINE)
1185 PARKFRSRIIRG RD : 115 / 135 SLAY&SAND
Mailing Address 135 / 141 SAND
GARI AND NG 2R441 141 / 160 SLAY&SAND
City or Town State Zip Code ; 12.REMARKS:
( 910 8 585-8624
Area code Phone number
6.WELL DETAILS: : 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 86 RECp D HAS BE I P130\7R D TO TH `LL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO / 04/15/20
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 23 FT. DAV i D L. R E I T R
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
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]
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