403521_Well Construction - GW1_20120220

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NONRESIDENTIAL WELL CONSTRUCTION RECORD Vi I
North Carolina Department of Environment and Natural Resources- Division of Water Quality 4 3 5 2,
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) #4
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural gif Recovery ❑ Injection 0
IrrigationD Other ❑ (list use)
DATE DRILLED 12-02-2011
4. WELL LOCATION:
565 ENEAS LANIER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTYDUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope DValley (Flat D Ridge DOther
LATITUDE 34 a 49 ' 16.7000 ° DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 43 , 4.7000 " DMS OR 7X.XXXXXXXXx DD
Latitude/longitude source: V3PS Dropographic map
(location of well must be shown on a USGS topo map andaftached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PINE NEEDLE FARMS
Facility Name
565 ENEAS LANIER ROAD
Street Address
CHINQUAPIN
City or Town
MIHN VU
Facility ID# (if applicable)
NC
State
28521
Zip Code
Contact Name
565 ENEAS LANIER ROAD
Mailing Address
CHJNQUAPIN
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 305
NC 28521
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L/
c. WATER LEVEL Below Top of Casing: 52 FT.
(Use "+" if Above Top of Casing)
: d. TOP OF CASING IS 1.5 FT. Above Land Surface*
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*Top of casing terminated at/or below land surface may require
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• 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
T• op 0 Bottom 207 . Ft. 4 _ 4__ 0 ___ PVC
Top 237 Bottom 243 Ft. 4 40 PVC
Top 268 Bottom 280 Ft. 4
8. GROUT: Depth Material
T• op 0 Bottom 20 Ft. HOLE PLUG
Ft.
Ft.
Top Bottom
: Top 'Bottom
9. SCREEN: Depth Diameter Slot Size Material
Top 207 Bottom 237 Ft. 4 in. .015 in. PVC
Top 243 Bottom 268 Ft. 4 in. .015 in. PVC
Top 280 Bottom 305 Ft. 4 in. .015 in. PVC
PVC
Method
POURED
1• 0. SAND/GRAVEL PACK:
Depth Size J7eiji
: Top 190 Bottom 316 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
1 '
11• . DRILLING LOG 4 U12 / ff.
: Top Bottom Foymation Description
265 1276
SAND AN�
276 / 287 .$AND
287 / 288
288 / 295
295 / 296
296 /315
ROCK
SAND
ROCK
SAND
315 / 316+ CLAY
1
1
1
1
12. REMARKS:
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
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1-24-12
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quaid - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09