410182_Well Construction - GW1_20121217

IN SIDENTI 1 WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
1 1
WELL CONTRACT() CE TIFICATI N # 2314A
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 22161
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT/kr applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring EI Municipal/Public
Industrial/Commercial D Agricultural
IrrigationD Other 0 (list use)
DATE DRILLED I I -28-12
Recovery 0 Injection
4. WELL LOCATION:
1200 S DOBSON CHAPEL ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: MAGNOLIA couNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
OSlope oValley 'Flat ORidge 00ther
LATITUDE 34 0 54 . 7.5000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 o 55 49.4000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 3PS 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.)
—BOSTIC FARMS
Facility Name Facility ID# (if applicable)
1200 S QOBSON CHAF'EL_ROAD
Street Address
MAGNDUA NC 28453
City or Town State Zip Code
BOSTIC FARMS
Contact Name
1200 S DOBSQN _CHAPEL RDA)
Mailing Address
MAGNOLIA
City or Town
State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 255
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO uf
c. WATER LEVEL Below Top of Casing: 46 FT.
(Use "+" if Above Top of Casing)
• 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): 125 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 235 Ft. 4 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
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 235 Bottom 255 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size
: Top 225 Bottom 260 Ft. #2
Top Bottom Ft.
iVlaterial
Top Bottom Ft.
•11
:11. DRILLING LOG
: Top Bottom
0 / 12
12 / 25
25 75
: 75 / 83
83 / 95
95 '/100
• 100 / 117
117 / 119
119• / 129
129 / 138
: 138 / 150
• •
12. REMARKS:
Formation*Mstriptien-_____
CLAY
SAND AND CLAY
SAND (MED)
ROCK AND SAND (MED)
SAND (MED)
SAND AND C AY
,OCK AND S
SAND (MED)
ROCK AND SAND
SAND (MED) °
nc r. I
IrliorMation Processing Unit
DwojBOG
• : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A N 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: REC HAS BEEN PVIDED T; THE WA OWNER.
1 V
• CW i''' .
SIGNATURE OF C 'TI
IED WELL ONTRACT
12-3-12
R DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Vie
•
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699461, Phone [phone]
Form GW-1 b
Rev. 2/09