GW1-2021-04494_Well Construction - GW1_20210429

NONRESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of v onment and Natural Resources-Division of Water Quality
WELL CONTRAC @h� RTIFIC TION# 2314A
1.WELL CONTRACTOR: � .-\4A :d. TOP OF CASING IS 1.5 FT.Above Land Surface"
DAVID L REGISTER Top of casing terminated ittor below land surface may require
Well Contractor(Individual)Name �Q Of a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO.. INC.
Well Contractor Company Name `, :e. YIELD(gpm): 50 METHOD OF TEST_AIR
721 WEST CHARITY ROAD f��0� If. DISINFECTION:Type HTH Amount 4 177
Street Address g. WATER ZONES(depth):
ROSE HILL 28458 :Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
9( 10 l 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#(K applicable) Top 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 Bottoms Ft. HOLE PLUG POURED
Irrigationffl(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 86 Ft. 4' in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in, in.
CITY: GARLAND COUNTYSAMPSON :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley VIFlat []Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMs oR N34.843702 DD Depth Size Material
LONGITUDE 78 ° Top 60 Bottom 86 Ft.#_ GRAVEL
"DMs OR W78.441437 DD ;Top Bottom Ft.
Latitude/longitude source: V3PS (]topographic map :Top Bottom Ft.
(location of well must be shown on a USGS topo map andettached 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
160 / 161 sAN D
Facility Name Facility ID#(if applicable) 161 1218 _SAND&CLAY
218 / 230 SAND FINE
Street Address- 230 /
City or Town State Zip Code /
WESL EY MELVIN /
Contact Name /
1165 PARKERSRURG RD /
Mailing Address /
GARL AND NG 98441 /
City or Town State Zip Code : 12.REMARKS:
( 910 _385-8624
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 86 :RE GLV'�D MAC EyiN PROM D TO T E WELL OWNER.
^, 04/15/20
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO L>� 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
Submit within 30 days of completion to: Division of Water Quality Form /09
y p ty- Information Processing, Rev.2/09
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone]