414681_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 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 Applicable Box): Residential Water Supply i (
DATE DRILLED 4-30-2013
TIME COMPLETED AM 0 PM 0
4. WELL LOCATION:
CITY: KENANSVILLE_.___- - ovnl r--D-l!P--L-I
113 W SCOTT ST. - HORSEBRANCH
Top 0
Top
Top
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Top
Top
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Bottom 200 Ft. 4 40 PVC
Bottom Ft.
Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bcttomn. Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 200 Bottom 210 Ft.4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
- —_ Depth
- =-: = T6p190 - Bottorn 218 Ft. #2
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 'Flat ❑ Ridge ❑Other
LATITUDE 34 ° 57 ' 35.7800 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 59 ' 42.3700 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: W&PS ❑Topographic map
rlocation of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
NICHOLAS AND SHANNON BELL
Owner Name
131 W SCOTT STREET
Street Address
KENANSVILLE NC 28349
City or Town State Zip Code
(910 ) 290-0241
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 210
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c. WATER LEVEL Below Top of Casing: 27 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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type,HTH Amount 4 OZ
Top Bottom Ft.
Top Bottom Ft.
Size
Material
� � E
11. DRILLING LOG ° e E R (. Ai ,.'<., ys,
Top Bottom Fgri .fip!J D.escriplion ', h.=, { 4 a �I
0 / 7 SAND AND '�CLi4 • : - 1 F .`: - .t . , ' ;
7 / 20 SAND
20 /25 CLAY
25 / 42 SAND (MED)
42
55
60
/55
/ 60
/68
68 / 69
69 / 73
73 / 85
85 / 100
100 /103
103 /107
107 /108
12. REMARKS:
CLAY
SAND (COARSE) ?CAVING IN
CLAY
ROCK 2"
CLAY
SAND (MED)
SAND AND CLAY
ROCK AND SAND
CLAY
ROCK 4"
J DO _HEREBY CERTIFYJAAT THIS WEE-.___W S.C_ON_STRU ED IN
ACCORDANCE WITH 15A"NCAC2C;_WELL"CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
7-3-13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CO
Submit within 30 d.ays of >vc�rnpfetion to. Division .of Water _Qtiah
• 1617 Mali Service Center, Raleigh;: NC 276�9 1 't,: Phone �'� 9} .807 fi3U0
tNIGUEM
JUL 2 2 20
ev. /09