GW1-2021-00411_Well Construction - GW1_20210129

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g NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
a;,,„mm• WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.5 FT.Above Land Surface*
DAVID L REGISTER *Top of casing terminated it/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 :f. DISINFECTION:Type HTH Amount 3 07
721 WEST CHARITY ROAD
Street Address : g. WATER ZONES(depth):
ROSE HILL NC 28458 :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#-PWS2020-1-00594- - -:-Top:-0--- --Bottom-76- -Ft. -4 -- 40-- --PVC---
OTHER ASSOCIATED PERMIT#(if 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
Irrigation(.Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 12/22/2020 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
FROG LEVEL ROAD :Top 76 Bottom 96 Ft. 4 in. 016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: WINTERVILLE COUNTY PITT ;Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley pj'Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 35 "Dons OR N3.5.530541 DD Depth Size Material
Top 70 Bottom 100 Ft.#_ GRAVEL
LONGITUDE 77 "CMS OR W77.441451 DD
— Top Bottom Ft.
Latitudellongitude source: V3PS Dropographic 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 /20 CLAY
Facility Name Facility ID#(if applicable) 20_/ 30 _SAND(COARSE)
_30 1 40 SAND&CLAY
--Street Add ress-- ------ ----
-- 4U / 60 -CLAY--
NG 60 / 69 SAND. CLAY&SHELLS
City or Town State Zip Code _69 /_70 ROCK 12"
TFRRY [-jFARHFART 70 / 99 SAND (MED)
Contact Name 99—/ ROCK
4393 FROG I FVF RnAI�
Mailing Address /
WINTFRVII I F NG, 98590- /
City or Town State r. Zip Code �O q 2 REMARKS:
(252� 916-8870 1
Area code Phone number
6.WELL DETAILS: I-PO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECO D AS BEEN P VIDED O THE W OWNER.
.
a. TOTAL DEPTH: 96 ` 1/22/21
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI : SIGNATURE OF CERTIFIED WELL 911IONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 12 FT. DAVID L. REGISTER .1
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality f Form /09 b
y p ty- Information Processing, Rev.2l09
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone]