GW1-2021-00952_Well Construction - GW1_20210404

a.A 1 r ONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
��•aao• WELL CONTRACTOR CERTIFICATION# 2314A
1.WELL CONTRACTOR: E C IVE D : d. TOP OF CASING IS 1.5 FT.Above Land Surface*
DAVID L REGISTER ; 'Top of casing terminated'atior below land surface may require
Well Contractor(Individual)Name APR ,� 2U21 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 r�afion Processing Unit f. DISINFECTION:Type HTH" Amount 4 n7
721 WEST CHARITY Ftl6A �
Street Address LjvvrN 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# :Top 00 Bottom 160 Ft. 4 40 PVC
p '
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 Bottom 20 Ft. HOLE PLUG POURED
Irrigation8{Other❑ (list use) Top Bottom Ft.
DATE DRILLED 02-1 1-21 Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
PENDERLEA-BURGAW HIGHWAY :Top 160 Bottom 180 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :TOp BOttOm Ft. in. in.
CITY: WALLACE COUNTY DUPLIN :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 °_' "DMS OR N34.618318 DID Depth Size Material
LONGITUDE 78 :Top 150 Bottom 193 Ft.!#2 _GRAVEL
"DMS OR W78.015599 DD :Top Bottom Ft.'
LatitudeAongitude source: { 3PS 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
0 / 14 CLAY
Facility Name Facility ID#(if applicable) 14 29 SAND
29 160 CLAY
Street Address 60 74 SAND&CLAY
4 178 MOCK(SOFT)
City or Town State Zip Code 78 / 117 CLAY
SHAWN WFI I R 117 1 120 SAND&CLAY
Contact Name 120 / 131 SAND(MED)
_5980 PFNDFRI FA HWY 131 / 132 _ROCK 6"
Mailing Address 132 / 136 SAND(MED)
WATHA N(: 28478 136 / 155 _ROCK&SAND
City or Town State Zip Code : 12.REMARKS:
t 910 231-0500
Area code Phone number
S.WELL DETAILS: :I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 180 RECO AS BEEN P D TO THE ILL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO G/
:SIGNATURE OF CERTIFIED WEL CONTRACTOR DA E-
c. WATER LEVEL Below Top of Casing: 35 FT. DAVID L. REGISTERI
(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]
i