404803_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.
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# 25233
NC
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigationd Other 0 (list use)
DATE DRILLED 4-12-2012
4. WELL LOCATION:
1430 S NC 111 HWY
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley Flat ❑Ridge ❑Other
LATITUDE 34 0 50 , 55.6000 °DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 42 , 59.8000 " 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.)
SLOAN FARMS
Facility Name
1430 S NC 111
Street Address
CHINQUAPIN
City or Town
WARREN SLOAN
Contact Name
1430 S NC 111
Ci n�
i
3
: 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): 75 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
: 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 Material
Top 196 Bottom 216 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
1• 0. SAND/GRAVEL PACK:
Depth Size Material
Top 190 Bottom 220 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11▪ . DRILLING LOG
Facility ID# (if applicable) = 188 / 217
•
•
A P
2; la Z[2
a
Top Bottom Formation Description • . on t:;�- ;` -�
179 /188
217 / 220+
/
NC 28521 /
State Zip Code : /
Mailing Address
CHINQUAPIN NC 28521
City or Town State Zip Code
4
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 216
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qi
c. WATER LEVEL Below Top of Casing: 29
(Use "+" if Above Top of Casing)
FT.
12. REMARKS:
SAND (MED FINE)
r K
ROCK AND SAND (MED)
ROCK. SAND AND CLAY
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECOR AS BEEN PROVIDED T THE ILL OWNER.
/S'1cUJ-c4L.
- :1 -
4 2012
• SIGNATURE OF CERTIFIED VVELL 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