GW1-2021-03920_Well Construction - GW1_20210823

1- NONRESIDENTIAL WELL CONSTRUCTION RECORD
"1 North Carolina Department of Environment and Natural Resources Division of Water Quality WELL CONTRACTOR CERT4MATION# 2314A
1.WELL CONTRACTOR: c°'
d. TOP OF CASING IS 1.5 FT.Above Land Surface'
DAVID L REGISTER `'''' c1 nn'11 'Top of casing terminated attor below land surface may require
Well Contractor(Individual)Name �C� C) ate` �t1�� a variance in accordance with 15A NCAC 2C.0.118.
REGISTER WELL CO.. INC. P ����`'j; e. YIELD(gpm): 50 METHOD OF TEST AIR
Well Contractor Company Name rr`;�✓.tQt\
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
9f 10 ) 289-3175 :Top IBottom Top Bottom
Area code Phone number Thickness!
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top-0 Bottom 230 Ft.i4 .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.'HOLE PLUG POURED
Irrigation❑ Other doist use) FIRE DEPT ;Top Bottom Ft.
DATE DRILLED 02/23/2021 :Top Bottom Ft.
4.WELL LOCATION: :S. 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. in. in.
CITY: HARRELLS COUNTY SAMPSON :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 34 "DMS OR N34.694550 DD Depth Size Material
LONGITUDE 78 :Top 225 Bottom 260 Ft.' #2 GRAVEL
"DMS OR W78.287846 DD ;Top Bottom Ft.
Latitude/longitude 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
b.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
HARREI i S EIRF DFPT 151 / 152 CROCK(1-THICK)
Facility Name Facility ID#(if applicable) 152 / 160 _'SAND (MED)
Sr
R0NCF Rn 160 / 161 CROCK(6"THICK)
Street-Address ----
- - -161 / 196 !SAND/CLAY MIX(MED)
HARREI US NC 28444 196 / 203 CLAY
City or Town State Zip Code 2-03 / 228 SAND/CLAY LAYERS(FINE)
228 1268 SAND(MED)
Contact Name 268 / ROCK
Mailing Address /
City or Town State Zip Code : 12.REMARKS:
Area code Phone number !
6.WELL DETAILS: : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 260 : REC RD S BEEN P VIDE TO THE,WE OWNER.
C
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI : SIGNATURE OF CERTIFIED WELL CONTRACTOR .05/10/21
c. WATER LEVEL Below Top of Casing: 41 FT. DAVID L. RE IST R
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
i
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form Wg-1b
1617 Mail Service Center, Raleigh,NC 27699-161,Phone:[phone]