403529_Well Construction - GW1_20120220

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
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#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) 4 1
3. WELL USE (Check One Box) Monitoring D Municipal/Public D
Industrial/Commercial D Agricultural i Recovery D Injection D
Irrigation❑ Other D (list use)
DATE DRILLED 1 1-15-201 1
4. WELL LOCATION:
565 EN EAS LANIER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley liefFlat D Ridge D Other
LATITUDE 34 ° 49 + 11.2000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 43 + 9.9000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: WPS DTopographic 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.)
PINE NEEDLE FARMS
Facility Name Facility ID# (if applicable)
565 ENEAS LAMER ROAD
Street Address
CHINQUAPIN NC 28521
City or Town State Zip Code
MIHN VU
Contact Name
565 ENEAS LANIER ROAD
Mailing Address
CHINQUAPIN NC 28521
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 305
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 51
(Use "+" if Above Top of Casing)
YES ❑ No q/
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): 40 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 207 Ft. 4 40 PVC
Top 232 Bottom 240 Ft. 4 40 PVC
Top 265 Bottom 280 Ft. 4 80 PVC
8. GROUT: Depth Material
: Top 0 Bottom 20 Ft. HOLE PLUG
: Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 207 Bottom 232 Ft. 4 in. .015 in. PVC
Top 240 Bottom 265 Ft.. 4 in. .015 in. PVC
Top 280 Bottom 305 Ft. 4 in. .015 in. PVC
1• 0. SAND/GRAVEL PACK:
Depth Size r
Top 200 Bottom 320 Ft. #1
Top
p Bottom Ft.
Top Bottom Ft.FEB 2 0 70 Z
:it DRILLING LOG �!
Top Bottom Form4tion Description
PY
Method
POURED
134 / 135
135 / 170
170 / 178
178 / 181
181 / 190
190 / 204
204 /216
216 / 229
229 / 237
237 / 250
250 / 258
12. REMARKS:
ROCK 4
CLAY
SAND MED FINE
ROCK 3' SOFT
CLAY
SAND AND CLAY
SAND MED FINE
ROCK AND SAND
CLAY = .
ROCK AND SAND MED FINE
SAND FINE
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
: DAVID L REGISTER
1-24-12
DATE
= PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09