GW1-2021-00475_Well Construction - GW1_20210210

1! NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
.'
WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: :d. TOP OF CASING IS 1.5 FT.Above Land Surface'
DAV I D L REGISTER 'Top of casing terminated atfor 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 :I. 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
9t 10 1 289-3175 :ToP Bottom Top Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 225 Ft.4_ 40 PVC
OTHER ASSOCIATED PERMIT#(a applicable) Top Bottom Ft.
SITE WELL ID#(R applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ :S. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 0 BottomlQ_Ft. HOLE PLUG POURED
Irrigadong{Other C7 (list use) :Top Bottom Ft.
DATE DRILLED.1/14/21 :Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
HWY 50 :Top 225 Bottom 255 Ft. 4 n. .016 in. PVC
(Sheet Name,Numbers,Community,Subdivislon,Lot No.,Parcel,Zip Code) :Top Bottom Fl._In. in.
CITY: KENANSVILLE couNTv DUPLIN Top Bottom Ft. In. _ in.
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Slope ❑Valley elat ❑Ridge ❑Other 10.SAN D/G RAVEL PACK:
LATITUDE 34 "DMS OR N34.904886 DD Depth Size Material
Top 990 Bottom 255 Ft#2 GRAVEL
LONGITUDE 77 "DMS OR W77.935782 DO :Top Bottom Ft
Latitude/longitude source: V3PS 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
172 / 173 ROCK 8"
Facility Name Facility ID#(if applicable) 173 / 185 SAND(FINE)
185 / 210 CLAY
Street Address 211 / 213 ROCK
213 / 243 SAND WED)
City or Town State Zip Code 245 ROCK
MFI ROSTIC ?.45_/ 255 SAND
Contact Name -255— CLAY
1900 S DORSON CHURCH ROAD
Mailing Address /
MAGN011A NC
City or Town $tatr';-ZIA obdid`
J : 12.REMARK8:
( 910is1 296-6203 201�
Area code Phone number
6.WELL DETAILS: f `:11 t bO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• taA NC AC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
e. TOTAL DEPTH: 255 - •RECO SaE(EN�PRONDE TO THE ELL OWNER.
IY M'L r
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO :SIGNATURE OF CERTIFIED EL CONTRACT ?J DA E
C. WATER LEVEL Below Top of Casing: 41 FT. DAVID I _ RFGISTFR
(Use"-"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1b
1617 Mall Service Center,Raleigh, NC 27699-161,Phone :[phone] Rev.2/09