411557_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#('d applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural Recovery 0 Injection 0
Irrigation0 Other ❑ (list use)
DATE DRILLED 1-8-2013
4. WELL LOCATION:
HUFFMANTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: RICHLANDS couwTYONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley piFlat ❑Ridge ❑Other
LATITUDE 34 =57 ' 7.0000 "DMS OR 3X.X)00000XXX DD
LONGITUDE 77 ° 33 • 29.2000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: IIDPS [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 HIIFFMAN
Facility Name - Facility ID# (if applicable)
HUFFMANTOWN ROAD
Street Address
RICH) ANDS NC 2857-4
City or Town State Zip Code
A .1 HI IFFMAN
Contact Name
612 RARRFE ROAD
Mailing Address
RICHI ANDS
City or Town
NC 28574
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES W NO 0
c. WATER LEVEL Below Top of Casing: 71 FT.
(Use "+" if Above Top of Casing)
411557
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance fn accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 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 Ft. 4 40 PVC
Top 250 Bottom 260 Ft. 4 80 PVC
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
Top 260 Bottom 300
Top Bottom
Top Bottom
Diameter Slot Size Material
Ft. 4 in. .015 in. PVC
Ft. in: in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 250 Bottom 315 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
297 / 299 ROCK 24" (HARD)
299 / 315+ SAND (VERY FINE)
12. REMARKS:
FRR %i)13
iruonnation Processinn
OWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ':'IN ACCOR *\KITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT Atop"(o ff s
RECORDi)AS DEENAtROVID¢p TO TyE WELL
OWNER.
1,31r.1,3/
SIGNATURE OF CERTIFIED LW L CONTRACTOR 'DOE
DAVID 1 . 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-1 b
Rev. 2/09