Wake County Well Contractor and Pump Installer Registration

Business Name

Business Owner's Name

First NameLast Name

Business Mailing Address (street or PO Box)

Street Address

Street Address Line 2

CityState

ZIP Code (5 digits only)

Business Phone

Please enter a valid phone number.Format: 000-000-0000.

Business Email Address

example@example.com

Services Offered? (optional, select as many as applicable)

Are you submitting a registration form for:

Bond

Personnel Certified by the North Carolina Well Contractors Certification Commission as a Well Contractor

List names, certification #, phone number, and email addresses

SP-WP Limited electrical license number

Personnel Authorized to Install Pumps

List names, certification #, phone number, and email addresses

I certify below that I am the owner of this business and the individuals listed above are aware of and understand the requirements of the Regulations Governing Well Construction and Groundwater Protection in Wake County as adopted by the Wake County Board of Human Services effective December 19, 2024. I understand that any person, firm or corporation violating any part of the Regulations or who willfully fails to perform any acts required by these Regulations shall by subject to sanctions as provided in N.C.G.S. 130A-25.

I certify below that I am the owner of this business and the individuals listed above are aware of and understand the requirements of the Regulations Governing Well Construction and Groundwater Protection in Wake County.

Please verify that you are human