414683_Well Construction - GW1_20130722

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 #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply frit
DATE DRILLED 5-9-2013
TIME COMPLETED AM D PM D
4. WELL LOCATION:
CITY: WALLACE
4537 S NC 41
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
7. CASING: Depth
Top 0 Bottom 85
414683
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 4 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 85 Bottom 100
: Top Bottom
Top Bottom
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
Ft.4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
_ Depth
----COUNTYDlJ_PLIN . - -
Top 80 ` Bottom 105 -
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope [Valley itFIat D Ridge D Other
LATITUDE 34 ° 46 ' 40.4000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77
54 , 37.1200 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
KENNETH CAVANAUGH
Owner Name
4537 S NC 41
Street Address
WALLACE NC 28466
City or Town State Zip Code
910 ) 285-5723
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 100
b. DOES WELL REPLACE EXISTING WELL? YES D NO L@f
c. WATER LEVEL Below Top of Casing: 5 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): 100 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 / 15 • SAND
Size Material
Ft. #2
Ft.
Ft.
Formation Description
15 /65 CLAY
65 /83 SAND (MED)
83 / 105+ ROCK AND SAND (MED)
/
i
12 REMARKS:
• I DO HEREBY CERTIFY THAT THIS W_ELL WAS CONSTRUCTED IN
ACCORDANCE WITH -15A -NCAC -2C, WELL -CONSTRUCTION •
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
• PROVIDED TO THE WELL OWNER
t � I!
z-'7 7-3-13
SIGNATURE OF CERTIFIED WELL IONTRACTOR DATE
DAVID L REGISTER, � .YEA
� •
PRINTED NAME OF PERSON = e: 1ST'
Submit within 30 clays of completion to: Division of Water Quality - Information Procesi
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
CTING THE WELL
2 2 2013
Form GW-1 a
Re'V? 2/09