414159_Well Construction - GW1_20120416

NONRESIDENTIAL WELL CONSTRUCTION RECORD
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
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #1
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural id Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 2-1-2012
4. WELL LOCATION:
JAMES ROAD 28466
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley fifFlat ❑Ridge ❑Other
LATITUDE 34 0 44 ' 55.9000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 45 ' 1.7000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: BPS ❑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
JAMES ROAD
Facility ID# (if applicable)
Street Address
PIN HOOK
City or Town
JAMIE WALKER
Contact Name
153 DAVID WALKER LANE
NC 28466
State Zip Code
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 275
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: 55 FT.
(Use "+" if Above Top of Casing)
t `11r
t' :
d. TOP OF CASING IS 1.5 FT. Above Land Surface* 't
*Top of casing terminated at/or below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 30 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 230 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 230 Bottom 275 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Bottom 292
Top 220
Top Bottom
: Top Bottom
: 11. DRILLING LOG
Top Bottom
Size Material
Ft. #1
Ft.
Ft.
Formation Description
203 / 208 SAND
208 / 215 CLAY
215 / 226 SAND AND CLAY
226 / 270 ROCK AND SAND (MED-FINE)
270 / 278 SAND AND CLAY
278 / 282 ROCK 4'
282 / 292 SAND (FINE)
292 / ROCK
/
12. REMARKS:
g 101\2
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONST M :
Ci:
,,
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANIJ" "MAT A Cejli
: RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S1
E-WITH
3-26-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L. REGISTER FE, V [-F:11 nri FE; �yl
• PRINTED NAME OF PERSON gCINSiTRUCTING.iTHE WELL i
APR 1 6 2012
Submit within 30 days of completion to: Division of Water Quality Information Pro eising,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
a
Foray GW-1 b
R2/09