403523_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 NC
City or Town
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #3
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural pif Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 1 1-22-201 1
4. WELL LOCATION:
565 ENEAS LAN IER ROAD
(Street Name, Numbers, Community,Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley elat ❑ Ridge
LATITUDE 34 ° 49 ' 15.6000
(check appropriate box)
❑Other
"DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 43 , 4.8000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: VIGPS ['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
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: 310
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 52
(Use "+" if Above Top of Casing)
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): 35 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 210 Ft. 4 40 PVC
Top 235 Bottom 245 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 210 Bottom 235 Ft. 4 in. .015 in. PVC
: Top 245 Bottom 265 Ft. 4 in. .015 in. PVC
Top 280 Bottom 310 Ft. 4 in. .015 in. PVC
10. SAND/GRAVEL PACK:
Depth
Top 200 Bottom
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
134 / 137
137 / 170
170 / 177
177 / 181
181 / 190
190 / 195
195 / 198
198 / 205
205 / 216
216 / 232
232 / 240
12. REMARKS:
Size
320 Ft. #1
Material
Fp
Ft.I
2 0 FEB � r
Ft. ,`� )
�2012
J
`I
Formation Description
ROCK j6!'
CLAY
SAND
ROCK AND SAND
CLAY
SAND AND CLAY
CLAY
SAND AND CLAY
SANDMEDFINE
ROCK HARD & SAND MED FIN
CLAY
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. •
1-24-12
SIGNATURE OF CERTIFIED WELL 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
I !: