411562_Well Construction - GW1_20130211

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#(If applicable)
SITE WELL ID #(d applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 1-3-2013
4. WELL LOCATION:
HUFFMANTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: RICHLANDS COUNTYONSLOW
TOPOGRAPHICI LAND SETTING: (check appropriate box)
❑Slope ❑Valley "Flat 0Ridge ❑Other
LATITUDE 34 ^ 57 •6.8000 "DMS OR 3X.XXXX000XXX DD
LONGITUDE 77 = 33 29.0000 " DMS OR 7X.XXX,30(XXX DD
Latitude/longitude source: [PPS ❑topographic 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.)
A .I HI 1FFMAN
Facility Name Facility ID# (if applicable)
HIIFFMANTOWN ROAD
Street Address
RICHI ANDS
City or Town
A .I HI IFFMAN
Contact Name
612 RARBEF ROAD
Mailing Address
RICHI ANDS
City or Town
NC 2857-4
State Zip Code
NC 28574
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 305
b. DOES WELL REPLACE EXISTING WELL? YES LV NO ❑
c. WATER LEVEL Below Top of Casing: 73 FT.
(Use "+" if Above Top of Casing)
411562
d. TOP OF CASING IS 1 5 FT. Above Land Surface*
"Top of casing terminated atlor 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 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 250 Et. 4 40 PVC
Top 250 Bottom 260 Ft. 4 80 PVC
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 260 Bottom 305
Top Bottom
Top Bottom
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
FL 4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material. ,--
Top 250 Bottom 320 Ft. #1 $ F I <f F D
Top Bottom Ft.
Top
Bottom Ft.
11. DRILLING LOG
Top Bottom
-EH 1.9 Z013
•;formation Processing Unit:
Formation DescriptioPWQ/SOG
0 / 19 CLAY
19 / 38 MARL AND CLAY
38 / 40 ROCK 18"
40 / 46 MARL
46 / 50 ROCK 4'
50 / 62 SAND AND CLAY
62 / 78 CLAY
78 / 86 SAND AND CLAY
86 / 110 ROCK AND SAND
110 / 130 ROCK. SAND AND CLAY
130 / 150 SAND (FINE)
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS
RECO AS Br MOM 0 THE ELL OWNER. h '
\.
1
Oalleet g` 7 i f 1 1-31-13`
SIGNATURE OF CERTIFIED WELL CONTRP&TOEe' n®L]ATE
DAVID L REGISTER cfl " _ �j)
L\J
PRINTED NAME OF PERSON CONSTR UCTIIt r Ct E'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-lb
Rev. 2/09