414074_Well Construction - GW1_20130610

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 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 NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(R applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation/ Other 0 (list use)
DATE DRILLED 5-22-2013
4. WELL LOCATION:
STAG PARK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BURGAW couNTYPENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley «Flat ❑Ridge ❑Other
LATITUDE 34 ° 33 ' 13.0400 "DMS OR 3X.xxx)0000x DD
LONGITUDE 77 ° 51 • 11.2500 " DMS OR 7x.xxxxxxXXx DD
Latitude/longitude source: 'PPS ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is Iodated.)
JAY MII AM
Facility Name
STAG PARK ROAD
Street Address.
Facility ID# (if applicable)
RIIRGAW NC 28,425
City or Town State Zip Code
JAY MII AM
Contact Name
STAG PARK ROAD
Mailing Address
RURGAW
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 235
NC: 28425
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c. WATER LEVEL Below Top of Casing: 16
(Use "+" if Above Top of Casing)
FT.
414074
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): 80 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
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 189 Ft. 4 40 PVC
Top-199 Bottom 210 Ft. 4 40 PVC
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE LUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 189 Bottom 199 Ft. 4 in. .015 in. PVC
Top 210 Bottom 235 Ft. 4 in. 015 in. PVC
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 180 Bottom 240 Ft. #2
Top Bottom -Ft. EC
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
JUN 10 2013
orotation Description
206 / 218 SAtJD (raEDM/6@b1E'CCAY
218 / 225 ROCK AND SAND
225 / 233 SAND
233 / 240+ CLAY
/
/
/
JUN
/ WATER QUALI 1 Y StG11UN
INFORMATION PROCESSING UNIT
12. REMARKS:
SIGNATURE OF CERTIFIED WELLION�TOR 5 DATE 3
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE HAS aENP VIDEEO THE LL OWNER.
Submit within 30 days of completion to: D vi lot of Water Quality L.Information Pro"ceasing,
1617Mail Service'Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09