407861_Well Construction - GW1_20121001

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO„ INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
•
*Top of casing terminated at/or below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Wpm): 100 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
Street Address
: g. WATER ZONES (depth):
ROSE HILL NC 28458 : Top Bottom Top
City or Town State Zip Code : Top Bottom Top
(910 ) 289-3175 : Top Bottom Top
Area code Phone number
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0 Bottom 110 Ft. 4
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring D Municipal/Public 0
Industrial/Commercial D Agricultural it Recovery D Injection D
Irrigation❑ Other 0 (list use)
DATE DRILLED 8-30-2012
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
40 PVC
• 8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
4. WELL LOCATION: ; 9. SCREEN: Depth Diameter Slot Size
976 BROWNTOWN ROAD : Top 110 Bottom 130 Ft. 4 in. .015
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: MAGNOLIA COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope [Valley Flat D Ridge D Other
LATITUDE 34 ° 53 . 13.4000 "DMS OR 3X.XXXxXXXXX DD
LONGITUDE 77 ° 55 ' 32.9000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 3PS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
OTIS BROWN
Facility Name Facility ID# (if applicable)
976 BROWNTOWN ROAD
Street Address
MAGNOI IA
City or Town
OTIS E�RC�W
Contact Name
976 BROWNTOWN ROAD
Mailing Address
MAGNOI IA
City or Town
C )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 134
State
Zip Code
NCl 284 3
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES p NO q�
c. WATER LEVEL Below Top of Casing: 33
(Use "+" if Above Top of Casing)
FT.
Method
POURED
Material
in. PVC
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 105 Bottom 132 Ft. #2
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
0 / 15 SAND AND CLAY
•
•
•
•
•
•
•
•
•
•
•
•
15 / 75 CLAY
75 / 99 SAND (MED)
99 / 111
111 I.130
130 / 132+
/
/
/
/
/
12. REMARKS:
ROCK AND SAND
SAND (MED)
CLAY
OCT o 1.20t2
. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A AC 2C, WEL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RED ' HAS BE ROVIDE0 THErWELL OWNER.
vtk,e,f 9-10-12
SIGNATURE OF CERTIFIES' ELL CONTRACTOR DATE
: DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Divis•
ion of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : (919) ::807-6300
nformation Processing,
Form GW-1 b
Rev. 2/09