414687_Well Construction - GW1_20130722

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 #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ( Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4-24-2013
4. WELL LOCATION:
: 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): 150 METHOD OF TEST AIR
: f. DISINFECTION: Type HTH Amount 4 OZ
: g. WATER ZONES (depth):
Top Bottom Top
: Top Bottom Top Bottom
Top Bottom Top Bottom
. Thickness/
:7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 40 PVC
: Top Bottom Ft.
: 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 Diameter Slot Size Material
620 VEACHS MILL ROAD : Top 245 Bottom 265 Ft. 4 in. .015
(Street Name, Numbers, Community, Subdivi-sio-arcel, Zip _Code)___ _ = -
Top_ Bottom ---
CITY: WARSAW COUNTY DUPLIN ; Top Bottom
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley elat ❑ Ridge ❑Other : 10. SAND/GRAVEL PACK:
Depth
Top 230 Bottom 270
LATITUDE 35
LONGITUDE 77
3 , 27.2000 " DMS OR 3x.xxxxxxxxx DD
58 ' 43.6000 „ DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VPS ['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.)
BOWLES BROTHERS
Facility Name Facility ID# (if applicable)
620 VEACHS MILL ROAD
Street Address
WARSAW NC 28398
City or Town State Zip Code
BOWLES BROTHERS
Contact Name
620 VEACHS MILL ROAD
Mailing Address
WARSAVY NC 28398
City or Town State Zip Code
( )
Area code Phone number
Top
Top
11. DRILLING LOG
: Top Bottom
•
•
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ni
c. WATER LEVEL Below Top of Casing: 9 FT.
(Use "+" if Above Top of Casing)
209
230
248
252
262
/ 230
/ 248
/ 252
/ 262
/ 270+
12. REMARKS:
Ft.
Ft.
Bottom
in. PVC
in. in.
in. in.
Size Material
Ft. #2
Bottom Ft.
Bottom Ft. SFr F•�.� <<ssr,�. n ��Y4:,:h:.�:1ti
Formation Description
MED SAND W/CLAY STREAKS
SAND (ME())
MED SAND W/CLAY STREAKS
SAND (MED)
MED SAND W/CLAY STREAKS
I DO HEREBY CERTIFY THAT THIS -WELL WAS -CONSTRUCTED IN ACCORDANCE WITH
• 15A NCA 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO� S BEEN P''VIDED TOT E WELL OWNER.
!4.L4
7-3-13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING T
•
Submit within 30 days of completion to: Division of Water Quality information Processi
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]