413399_Well Construction - GW1_20130513

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
City or Town
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Rif applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply lir
DATE DRILLED 3-26-13
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: BURGAW COUNTY PENDER
NEW SAVANNAH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
ID Slope ❑Valley mfFlat ❑Ridge ❑Other
LATITUDE 34 ° 34 ' 4.7000
LONGITUDE 77 ° 57 59.8000
" DMS OR 3x.xxxxxxxxx DD
" DMS OR 7x.xxxxxxxxx DD
Latltude/longitude source: [ti 3PS 0Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
CROSSROADS CONSTRUCTION
Owner Name
1741 HWY117N
Street Address
BURGAW NC 28425
City or Town State Zip Code
[phone]
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 220
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g
c. WATER LEVEL Below Top of Casing: 35 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): 25 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
9.
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 210 Ft. 2 40 PVC
Top Bottom Ft.
Top Bottom Ft.
/1 n0 09
WATER ZONES (depth):
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 210 Bottom 220
Method
POURED
Diameter Slot Size Material
FL2 in. .015 in. PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 200 Bottom 220 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /16 CLAY
16 /35
Formation Description
SAND (COARSE)
35 /80 CLAY
80 /95
SAND AND CLAY
95 /135 CLAY
135 /136
136 /150
150 /153
ROCK 3"
SAND AND CLAY
ROCK AND CLAY
153 /190 CLAY
190 /191
ROCK 8"
191 /198 SAND
198 /199
199 /220+
/ MAY
12. REMARKS:
ROCK 2"tt
SAND (M.€
tr
4M' 13200
i"iroRMA`I l I Y SFC T-40N
WATER QUk"L"
Olv NItRGES31NGa.ly(r_
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
PRQVIDED TO THE WELL OWNER.
LSO/ 4-30-13
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-la
Rev. 2/09