413946_Well Construction - GW1_20130610

;r. c ry
r;1
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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 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)
3. WELL USE (Check Applicable Box): Residential Water Supply We
DATE DRILLED 5-21-2013
TIME COMPLETED AM ID PM ID
4. WELL LOCATION:
CITY: WATHA COUNTYPENDER
202 SWANN LAKE CIRCLE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley yilFlat ['Ridge ❑Other
LATITUDE 34 ° 40 • 52.1300 "DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 56 • 38.2100 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: IfPS I7ropographic map
(location of well must be shown on a US9S topo map andattached to
this form if not using GPS)
5. WELL OWNER
MARGARET HODGES
Owner Name
202 SWANN LAKE CIRCLE
Street Address
WATHA NC 28478
City or Town State Zip Code
L—)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 202
b. DOES WELL REPLACE EXISTING WELL? YES NO ❑
c. WATER LEVEL Below Top of Casing: 33 - FT.
(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): 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
TopO Bottom 187
Top Bottom Ft.
n13046
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 2 40 PVC
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Material Method
Ft. HOLE PLUG POURED
Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 187 Bottom 202 Ft.2 in. .015 in. PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 170 Bottom 215 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
172 /173
173 /178
178 /202
202 /204
204 /205
205 /215
/
12. REMARKS:
in.
in.
Material
Formation Description
ROCK 4"
SAND AND CLAY
SAND (MED)
SAND AND CLAY
ROCK 3"
SAND AND CLAY
BY:
'd' Al E "QUAi r"% `3I::ci k
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE -WITH15ANCAC-2C;WELtCCONSTRUCIION --
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO)1ftD TO THE WELL 0 NER.
S[GNATURE OF CERTIFIED W
DAVID L REGISTER
5-30-13
L CONTRACTOR DATE
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