404802_Well Construction - GW1_20120425

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.
Wet 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# 25233
NC
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationii Other ❑ (list use)
DATE DRILLED 4-12-2012
4. WELL LOCATION:
1 430 S NC 111 HWY
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTYDUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
iJ Slope ❑ Valley wifFlat DRidge ❑Other
LATITUDE 34 ° 50 ' 55.6000 n DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 42 ' 59.8000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: Qj3PS [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.)
SLOAN FARMS
Facility Name
1430 S NC 111
Facility ID# (if applicable)
Street Address
CHINQUAPIN NC 28521
City or Town State Zip Code
WARREN SLOAN
Contact Name
1430 S NC 111
Mailing Address
CHINQUAPIN NC 28521
City or Town State Zip Code
{ )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 216
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Get
c. WATER LEVEL Below Top of Casing: 29
(Use "+" if Above Top of Casing)
FT.
:d
•
•
4 3
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): 75 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 196 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
Top 196 Bottom 216 Ft. 4 in. .015
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 190
Top
• Top
11. DRILLING LOG
: Top Bottom
0 / 15
Bottom 220 Ft. #2
Bottom
Bottom
Ft.
Ft.
Material
in. PVC
in.
in.
Material
�frw3�'
!` R
1.017_
Formation Description
SAND
15 / 20 CLAY
20 / 25 SAND AND SHELLS
• 25 / 40 CLAY
• 40 / 45 ROCK AND SAND
45 / 84 BAND AN Q LAY
84 / 85 ROCK 6"
85 / 99 SAND
: 99 / 135 SAND AND ROCK (MED FINE)
135 / 162 SAND AND ROCK (MED)
162 / 179 CLAY
• 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
• RECOLIRSIHAS BEEN P VIDED TO T WELL OWNER.
f
4-20-12
SIGNATURE OF CERTIFIED W LL CONTRACTOR 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
Unit pr.•