405414_Well Construction - GW1_20120605

P'NisiDEivriAL WELL CO1',,ISTRUCTEON RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR. CERTEFICATEON # 2314A
1. WELL CONTRACTOR:
DAVID REGISTER
RECD JUN 0 5 2012
Well Contractor (Individual) Name
REGISTER WELL CO, INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
(9/0 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* 25287
NC
State Zip Code
28458
OTHER ASSOCIATED PERMIT*(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public D
Industrial/Commercial 0 Agricultural dr Recovery El njection
IrrigationD Other 0 (list use)
DATE DRILLED 4-23-2012
4. WELL LOCATION:
CYPRESS CREEK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top Bottom Ft. in. in.
CITY: 'CHINQUAPIN COUNTY DUPLON Top Bottom Ft. in. in.
d. TOP OF CASING IS ,5 FT. Above Land Sun'ace"
• Top of casino- terminated atlor beiow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 150+ METHOD OF TEST AIR
: f. DISINFECTION: Type HITH, ArrtGunt
: g. WATER ZONES (depth)
Top Bottom Top Bottom
: Top Bottom Top Bottom
▪ Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 105 Ft. 4 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
: Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
▪ Top 105 Bottom 130 Ft. 4 in. .015 in. PVC
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope DValley Flat DRidge DOther
LATITUDE 34 46 8.8000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDETT 42 32.1000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: MPS aopographic 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.)
Facility Name
Street Address
Facility ID* (if applicable)
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 100 Bottom 137 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0 15 SAND
Formation Description
15 / 21 CLAY
▪ 21 / 28 MARL
28 / 33 ROCK
33 / 70 MARL AND ROCK
City or Town State Zip Code • 70 / 85 MARL AND CLAY
S1FORGED_OLSEK : 85 / 97 CLAY
Contact Name • 97 / 123 MARL AND ROCK
2659 S NO 41
Mailing Address
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: I 30
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ri
c. WATER LEVEL Below Top of Casing: 17 FT.
(Use "+" if Above Top ofCasing)
123 / 132 (MED) SAND
• 132 137+ CLAY
2. REMARKS:
.1 A \I s:e. r)
15A N
• RECO
ti
•
I. V, 6/ 61 5-15-12
...
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
AC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
D HAS BEEN PROVIDED 0 THE WE OWNER.
: DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of complletion to: Division of Water Quallity - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-1 b
Rev. 2/09