GW1-2021-00547_Well Construction - GW1_20210219

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NONRESIDENTIAL WELL CONSTRUCTION RECORD g
North Carolina Department of Environment and Natural Resources-Division of Water Quality q
•�a,�„�• WELL CONTRACTOR CERTIFICATION# 2314A 1
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1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.5 1 FT!Above Land Su MOD
DAVID L REGISTER "Top of casing terminated at/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): 50 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
9t 10 289-3175 :Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 52 Ft.-4 .40 PVC
—OTHER ASSOC-IATED-PERMIT#(ifapplicable)- _ Top 72 Bottom 102 Ft. 4 __ .40 PVC
SITE WELL ID#(if applicable) :Top 109 Bottom 118 Ft.-4 .40 PVC
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
IrrigationN(Other❑ (list use) Top Bottom Ft.
DATE DRILLED 02/04/21 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
RAWHIDE RD :Top 52 Bottom 72 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top 102 Bottom 109 Ft. 4 n. .016 in. PVC
CITY: NEWTON GROVE COUNTY SAMPSON :Top 118 Bottom 131 Ft.-4 in. .016 in. PVC
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley J(Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 35 "DMS OR N35.217492 DD Depth Size Material
Top 40 Bottom 140 Ft. 02 GRAVEL
LONGITUDE 78 "DMS OR W78.305342 DO
Top Bottom Ft.
LatitudeAongitude source: V3PS ❑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
S.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
WF PARTNFRSHIP 0 10 CLAY
Facility Name Facility ID#(if applicable) 10—/ 25 SAND
5 / 41 CLAY
_ -----Street_Address—.----------.-:
2 172 — SAND(MED)
City or Town State Zip Code 72 1 102 CLAY
GERM D WARRFN 102 / 106 SAND(MED)
Contact Name 106 / 118 CLAY
PO BOX 923 : 118 / 131 SAND(MED)
Mailing Address 131 / CLAY
NEWTON GROVF NG, 983R6 /
City or Town State Zip Code
12.REMARKS:
( 910 385-5094
Area code Phone number
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC AC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 131 REc HAS BEEJOVID?OTHEW OWNER.
41.//� i02/12121
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI : SIGNATURE OF CERTIFIED WELL NTRAC OR DATE
c. WATER LEVEL Below Top of Casing: 10 FT. DAVID L. REGISTER
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
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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