406920_Well Construction - GW1_20120813

AT
ESI
ENTIAL WELL CONST
UCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTEFICATRON # 2314A
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO., INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public
Industrial/Commercial 0 Agricultural D Recovery 0 Injection 0
Irrigation5I Other 0 (list use)
DATE DRILLED 12-6-2011
4. WELL LOCATION:
FOUNTAINTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BEULAVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
OSlope 0Valley Flat 0 Ridge 00ther
LATITUDE 34 052 16.7000 f, DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 42 10.3000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: EXPS ['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.)
CECIL LANIER
Facility Name Facility ID# (if applicable)
i01.1NTAINIQINN ROAD
Street Address
BEULAVILLE NC 28518
City or Town State Zip Code
CECIL LANIER
Contact Name
809 E BROAD STREET
Mailing Address
BEULAVILLE NC 28518
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 275
b. DOES WELL REPLACE EXISTING WELL? YES Cit NO
c. WATER LEVEL Below Top of Casing: 26
(Use "+" if Above Top of Casing)
FT.
Top 245
Top
Top
11. DRILLING LOG
: Top Bottom
197 / 200
200 / 201
201 / 202
: 202 / 207
217/ 210
210 / 215
215 / 252
252 / 257
257 275
275 / 277
277 / 280+
12. REMARKS:
Size Material
Ft. in
Ft.
Ft.
t-f
=
Formation 10)
CLAY
ption
SAND -
ROCK 6"
SAND (MED)
ROCK 3'
ROCK AND SAND (FINE)
SAND (FINE)
ROCK AND SAND (MED FINE)
SAND (MED FINE)
ROCK AND SiVq12-=- '
SAND (FIN
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN.ACCOROANCE WITH
15A NC
RECOIRD
692
: d. TOP OF CASING IS 1.5 FT. Above Land Surface*
• *Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 METHOD OFTEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom 255
: Top Bottom
Top Bottom
8. GROUT: Depth
Top 0
: Top
Top
Bottom 20
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 2 .40 PVC
Ft.
Ft.
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 255 Bottom 275 Ft. 2 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Bottom 280
Bottom
Bottom
7-24-12
SIGNATURE OF CERTIFIED WELL' ONTRAC-TOR DATE
: DAVID L. REGISTER
2C, WELL CONSTRUCTION STANDARDS, AND THAT)COPY OFM1-IIS
AS BEEN P,OVIDEDA0 THE LL OWNER.
1/47:,; CLA,Vdt. k- --441
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09