403417_Well Construction - GW1_20120220

NONRESIDENTIAL WELL CONSTRUCTION RECORD I Oo
4034n
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 State
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #5
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ( Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 11-30-2011
4. WELL LOCATION:
565 ENEAS LAN I ER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING:
❑ Slope [Walley hifFlat ❑ Ridge
LATITUDE 34 ° 49 17.3000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 43 3.4000 " DMS OR 7X.XxxxXXxXX DD
Latitude/longitude source: WGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS)
5. FACILITY (Name of the business where the well is located.)
(check appropriate box)
❑Other
PINE NEEDLE FARMS
Facility Name Facility ID# (if applicable)
565 ENEAS LAN I ER ROAD
Street Address
CHINQUAPW NC 28521
City or Town State Zip Code
MIHN VU
Contact Name
565 ENEAS LAN I ER 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 u+" if Above Top of Casing)
NO qf
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 208 Ft. 4 4_ PVC
Top 233 Bottom 245 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
Top 208 Bottom 233
Top 245 Bottom 265
Top 280 Bottom 310
10. SAND/GRAVEL PACK:
Depth
Top 190 Bottom 330
Top Bottom
Top Bottom
11. DRILLING LOG
: Top Bottom
239 / 252
Method
POURED
Diameter Slot Size Material
Ft. 4 in. _la in. PVC
Ft. 4 in. .015 in. PVC
Ft. 4 in. .015 in. PVC 2,
Mate ,,aIt
252 / 260
260 / 262
262 / 276
276 / 287
287 / 288
288 / 294
2 4 / 296
296 / 306
• 305 / 307
307 / 314
12. REMARKS:
Size
Ft. #1
Ft.\c\�v
Ft.���\
Formation Desri tion`'
ROCK AND SAN
SAND FINE
ROCK AND SAND
CLAY
SAND FINE
ROCK
SAND FINE
ROCK 24"
SAND FINE
ROCK 8"
SAND
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-'I b
Rev. 2/09