404797_Well Construction - GW1_20120425

NONRESIDENTIAL WELL CONSTRUCTION RECORD 0 I 7 ( 7
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)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationCj Other ❑ (list use)
DATE DRILLED 4-12-2012
4. WELL LOCATION:
PINE RIDGE - RIVER LANDING
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WALLACE COUNTY DUPLIN ; Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley itlat ❑ Ridge DOther
LATITUDE 34 0 44 , 38.0000 „ DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 56 ' 4.7000
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: IZ3PS :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.)
RIVER LANDING
Facility Name
PINE RIDGE
Facility ID# (if applicable)
Street Address
WALLACE NC 28466
City or Town State Zip Code
CHRIS HERRING
Contact Name
PO BOX 1139
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
( }
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1Q5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qi
c. WATER LEVEL Below Top of Casing: 14
(Use "+" if Above Top of Casing)
FT.
: 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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3_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 85 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
9. SCREEN: Depth
Top 85 Bottom
Top Bottom
Bottom
Bottom Ft.
Diameter Slot Size Material
105 Ft. 4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 80 Bottom 107 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
•
11. DRILLING LOG
: Top Bottom
•
0 /18
18 / 30
30 / 50
50 / 65
65 / 70
70 / 77
77 / 86
86 / 87
87 / 97
97 / 98
98 / 105
12. REMARKS:
Formation Description
SAND
SAND AND CLAY
SAND
CLAY
SAND
CLAY
SAND
ROCK 12" T' is
SAND (MED)
ROCK 14"
1,,17411,
a 1 f,
SAND (MED)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECKT HAS BEENPROVIDED TITHE V1,�ELL OWNER.
.9 LA:604
SIGNATURE OF CERTIFIED
4-18-12
ELL 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