403527_Well Construction - GW1_20120220

N
NON RESIDENTIAL 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 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) #2
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural NI Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 1 1-15-2011
4. WELL LOCATION:
565 ENEAS LANIER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley VFlat ❑ Ridge ❑Other
LATITUDE 34 ° 49 ' 12.5000 „DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 43 , 7.7000 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.)
PINE NEEDLE FARMS
Facility Name Facility ID# (if applicable)
565 ENEAS LANIER ROAD
4 0 3 4
: 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): 50 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 Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
: 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 S.Fre r ri
: Top 200 Bottom 320 Ft. #1 RJR 1
j n
FE.B 2 0 2.O'\2. Est
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
•
• 277 / 284
284 / 287 ROCK AND SAND
287 / 294 SAND FINE
294 / 296 ROCK 30" HARD
296 / 310 SAND FINE
310 / 320+ CLAY
/
a©nBesti`ipllon
SAND FINE
.
•
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? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: 51 FT.
(Use "+" if Above Top of Casing)
•
•
.
• 12. REMARKS:
•
' it —CV/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED: IN_ ACC©RDANCEWITH'
• 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 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09