Registration of Well Contractors
This PDF document may not meet current accessibility standards (WCAG 2.1 AA) and may not be fully usable with assistive technologies.
If you require access to the information in a more accessible format, please e-mail webstaff@johnstonnc.gov and we will provide an alternative version as soon as possible. A machine-generated text version is also available below.
We apologize for any inconvenience and appreciate your understanding as we work toward full accessibility compliance.
If the document does not display above, download the PDF.
Text version (machine-generated from the PDF)
10 JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 309 East Market Street , Smithfield , NC 27577 309 East Market Street , Smithfield , NC 27577 Phone 919 - 989 - 5180 Phone 919 - 989 - 5180 Fax 919 - 989 - 5190 Fax 919 - 989 - 5190 Email septicwellapplication @ johnstonncgov septicwellapplication @ johnstonncgov REGISTRATION OF WELL CONTRACTORS REGISTRATION OF WELL CONTRACTORS 1 Name of Firm 1 Name of Firm _____________________________________________________________________________ _____________________________________________________________________________ 2 Business Address _ 2 Business Address _ ______________________________________ Business Phone _ ____________________ ______________________________________ 3 Responsible Person _ _____________________________________ Mobile Phone ______________________ Business Phone _ ____________________ 4 Email address _ ____________________________________________________________________________ 3 Responsible Person _ _____________________________________ 5 Check 1 of the following New Renewal No longer in business Mobile Phone ______________________ 6 Number & type of well rigs used in construction 4 Email address _ No # Type Serial Number ____________________________________________________________________________ a __________________ _ _____________________________________ ____ ___________________ 5 Check 1 of the following New Renewal No longer in business b __________________ _ _____________________________________ ____ ___________________ 6 Number & type of well rigs used in construction No # Type Serial Number c __________________ _ _____________________________________ ____ ___________________ a __________________ d __________________ _ _____________________________________ ____ ___________________ _ _____________________________________ 7 Type of well constructed Bored Diameter _ _________________________________ ____ ___________________ Drilled Diameter __ ________________________________ b __________________ Gravel Pack Diameter _ _________________________________ _ _____________________________________ Other Diameter _ _________________________________ ____ ___________________ 8 North Carolina well certification Numbers c __________________ Names _ ______________________________________________ No # _________________________ _ _____________________________________ ____ __________________________________________________ No # _ _________________________ ____ ___________________ _ _____________________________________________________ No # _ _________________________ d __________________ _ Signature _ ____________________________________________ Date _____________________________ _____________________________________ ____ ___________________ FOR DEPARTMENT USE ONLY 7 Type of well constructed Bored Diameter _ _________________________________ REGISTRATION NUMBER _ ___________________________ DATE _____________________ Drilled Diameter __ ________________________________ Gravel Pack Diameter _ _________________________________ Other Diameter _ _________________________________Page