404152_Well Construction - GW1_20120416

NONRESIDENTIAL WELL CONSTRUCTION RECORD _ 0
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L. REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO., INC.
Well Contractor Company Name
72 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural id Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 2-9-2012
4. WELL LOCATION:
FOUNTAINTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley elat D Ridge DOther
LATITUDE 34 0 50 , 56.1000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 a 40 ' 23.9000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: MPS ❑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.)
Facility Name Facility ID# (if applicable)
FOUNTAINTOWN ROAD
Street Address
NC
City or Town State Zip Code
MICHAEL SHOLAR
Contact Name
14008 MARLED H LANE
Mailing Address
C L I FTO N VA 20124
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 258
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: 45 FT.
(Use u+" if Above Top of Casing)
Submit within 30 days of completion to: Division of Water Quality - Information Processing,1�T
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
O4152
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 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 238 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 238 Bottom 258 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 225 Bottom 259
Size
Ft. #2
Material
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
:• 0 / 20 SAND
• 20 / 42 CLAY
• 42 / 50 ROCK AND MARL
• 50 / 60
60 / 100
100 / 115
▪ 115 /143
• • 143 /144
• 144 /160
• 160 / 200
12. REMARKS:
ROCK AND SAND
CLAY
SAND (FINE)
SAND AND CLAY
ROCK 4"
SAND A
SAN:
•
\\AO,
;j•C\-11
cOi10OCi
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECO' s HAS BEEN PROVIDED T THE WELL OWNER.
i're0 r
au.•.
. 3-20-
12
SIGNATURE OF CERTIFIED ELL CONTRACTOR DATE
• DAVID L. REGISTER h r-� ►'.3 1 ` i,
PRINTED NAME OF PERSON CONSTRUCTINGTHE^WELL
, APR 1.6 2012 , I
Form GW-tb}
• Rev. 2/09