404916_Well Construction - GW1_20120502

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
Street Address
ROSE HILL NC 28458
City or Town State Zip Code
910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) OXFORD PLACE
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationd Other ❑ (list use)
DATE DRILLED 3-12-12
4. WELL LOCATION:
131 OXFORD COURT
(Street Name, Numbers, Community, Subdivision, .Lot No., Parcel, Zip Code)
CITY: BEULAVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Valley wiFlat ❑ Ridge DOther
LATITUDE 34 ° 54 , 55.7000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 46 ' 5.9000 " DMS•OR 7x.xxxxxxxxx DD
Latitude/longitude source: liZGPS ❑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.)
OXFORD PLACE APT_
Facility Narne Facility ID# (if applicable)
131 OXFORD COURT
: 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 (gpm): 125 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
: 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 170 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 170 Bottom 185 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top 160 Bottom 187 Ft. #2
Top
Top
11. DRILLING LOG
: Top Bottom
0 /15
•
Street Address •
BEULAVILLE NC 28518
City or Town State Zip Code •
NORCO MANAGEMENT INC_
Contact Name
PO BOX 1502,5
138 /147
Bottom
Bottom
Ft.
Ft.
REE€EIVED
MAY
2012
Information Processing Unit
DWQ/BOG
Formation Description
CLAY
15 / 45 SAND AND CLAY
45 / 105 CLAY
105 / 110 SAND
110 / 115 SOFT ROCK 5'
115 / 122 SAND AND CLAY
122 / 123
ROCK 6"
123 / 137 SAND AND CLAY
137 / 138 ROCK 8"
Mailing Address
W I LM I N GTO N NC 28408
City or Town • State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 185
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 49
(Use "+" if Above Top of Casing)
NO qi
FT.
•
SAND
147 / 165 ROCK AND SAND
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD , - BEEN PROVI ED T9IHE WE OWNER.
• rt--� 4-27-12
SIGNATURE OF CERTIFIED WELL cG/ TRACTOR DATE
DAVID L. REGISTER
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