GW1-2021-00957_Well Construction - GW1_20210404

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1 r ONRESIDENTML WELL CONSTRUCTION RECOR& 4 2021
North Carolina Department of Environment and Natural Resources-Division of Water Qua tty
•mr ; ar• WELL CONTRACTOR CERTIFICATION# 2314A !Informption Processing Uni,
i vVVIR Section
1.WELL CONTRACTOR: : d. TOP OF CASING IS 1.5 FT.Above Land Surface"
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):�35 METHOD OF TEST AIR
Well Contractor Company Name 721 WEST CHARITY ROAD :f. 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
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 0 Bottom 150 Ft. 4 40 PVC
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OTHER ASSOCIATED PERMIT#('rf 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
Irrigationt(Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 02-15-21 Top Bottom Ft.
4.WELL LOCATION: ;9. SCREEN: Depth Diameter Slot Size Material
PENDERLEA-BURGAW HIGHWAY :Top 150 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:
Depth Size Material
LATITUDE "DMS OR N34.612543 DD :Top 145 Bottom 180 Ft. #2 _GRAVEL
LONGITUDE 78 "DMS OR W78.010365 DD
— Top Bottom Ft.
Latitude/longitude source: {BPS OTopographic 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
0 14 _CLAY
Facility Name Facility ID#(if applicable) 14 29 SAND
29_/ 60 CLAY
Street Address 60 / 74 SAND&CLAY
74 178 ROCK(SOFT)
City or Town State Zip Code 78 117 CLAY
SHAWN WFI I S 117 / 120 SAND&CLAY
Contact Name 120 / 131 SAND(MED)
. . 80 PFNDFRI FA HWY 131 / 132 ROCK 6"
Mailing Address 132 / 136 SAND(MED)
WATHA NC: 28478 136 / 155 ROCK SAND LAYERS
City or Town State Zip Code : 12.REMARKS:
( 910 231-0500
Area code Phone number
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C.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
8. TOTAL DEPTH: 180 RECO S BEE PRO ED TO T E WELL OWNER.
o-` t 4/5/21
b. DOES WELL REPLACE EXISTING WELL? YES p NO qI : SIGNATURE OF CERTIFIED LLJ CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 35 FT. DAVID LL REGISTER!
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form Rev.2/09/09
1617 Mail Service Center,Raleigh,NC 27699-161,Phone: [phone] !
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