GW1-2021-03919_Well Construction - GW1_20210823

a"`sr'atF'�
NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
��• •>^� _
a#�,�,,,,o• WELL CONTRACTOR CEP.,TIFICATION# 2314A
1.WELL CONTRACTOR: a�" ^� :d. TOP OF CASING IS 1.5 FT.Above Land Surface`
DAVID L REGISTER � � "Top of casing terminatediatlor below land surface may require
Well Contractor(Individual)Name •t-- o a variance in accordance with 15A NCAC 2C.0118.
REGISTER WELL CO INC. J �� ;e. YIELD(gpm): 50 METHOD OF TEST AIR
Well Contractor Company Name � �On :f. DISINFECTION:Type HTH' Amount 3 nZ
721 WEST CHARITY ROAD :,,n�' aLC2
Street Address r��\7 `•�� , :g. WATER ZONES(depth):
ROSE HILL ��'�., IZ 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 230 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 Bottom_20 Ft. THOLE PLUG POURED
Irrigation❑ Other W(list use) FIRE DEPT Top Bottom Ft.
DATE DRILLED 02/23/2021 ;Top Bottom Ft.
4.WELL LOCATION: ;9. SCREEN: Depth Diameter Slot Size Material
SCRONCE RD :Top 230 Bottom 260 Ft. 4 in. .016 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
Top Bottom Ft. I in. in.
CITY: HARRELLS COUNTY SAMPSON :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley WfFlat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMS OR N34.694550 DD Depth Size Material
LONGITUDE 78 Top 225 Bottom 260 Ft. #2 GRAVEL
"DMS OR W78.287846 DO :Top Bottom Ft.'
Latitudellongitude source: V3PS Qfopographic 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
_ HARREI I S FIRF DFPT 0 / 5 (SAND
Facility Name Facility ID#(if applicable) 5 / 11 iCLAY
.RGRQNC.F RD 11_1 14 SAND(COURSE)
Street Address_ 14 1 16 CLAY
HARRFI I S NG 98444 16 1 29 _SAND (COURSE)
City or Town State Zip Code 29 / 31 1CLAY
31 / 39 iSAND/CLAY MIX
Contact Name -39 185 SAND(COURSE)
5 195 CLAY
Mailing Address 95 120 _SAND MUD MIX(FINE)
120 / 151 :SAND(FINE)
City or Town State Zip Code ' 12.REMARKS:
U
Area code Phone number
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL"WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCX 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 260 RECO S BEEN P VIDE O THE LL OWNER.
^, f
b. DOES WELL REPLACE EXISTING WELL? YES El NO Ltl� SI NATURE OF CERTIFIED WELL ONTRACTOR D10/2 ATE
c. WATER LEVEL Below Top of Casing:_9.1 FT. :_ DAVID L. REGISTER
(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 G 9 1b
1617 Mail Service Center,Raleigh,NC 27699-161, Phone:[phone]
i