414505_Well Construction - GW1_20130708

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 414505
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L 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
NC 28458
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCT!ON PERMIT# W 13-08108
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply (f
DATE DRILLED 6-17-2013
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: IVANHOE couNTYPENDER
13757 SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley f/fFlat ❑Ridge DOther
LATITUDE 34 = 36 • 0.5500 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 78 011 • 07.8800 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: GeGPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
RICHARD KERR
Owner Name
13757 SHILOH ROAD
Street Address
IVANHOE
City or Town
NC 28447
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL. DEPTH: 118
b. DOES WELL REPLACE EXISTING WELL? YES d NO ❑
------erWATER LEVEL -Below -Top -of Casin- -_
(Use "+" if Above Top of Casing)
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): 75 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 103 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 103 Bottom 118
Ft.4
Top Bottom Ft.
Top Bottom Ft.
in. .015 in. PVC
in. in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top95 rt Bottom 118 -Ft:#2 -_ - ---
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /32
32 /40
40 /60
60 /80
80 /95
95 /118
118 /
/
12. REMARKS:
Formation Description
SAND
SAND AND CLAY
CLAY
SAND (MED)
ROCK AND SAND
SAND (MED)
ROCK
tVA EI CIUALITI ' SEC K,JN
fur eifri-(u*ssiNG um
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSSRUCTFnJN,__
ACCORDANCE WITH 15A NCAC2CiVELt-CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVDTELL OWNER.
CC11 f C!!�//)• t
6-18-13
SIGNATURE OF CERTIFIED W �L 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-la
Rev. 2/09