414680_Well Construction - GW1_20130722

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment an'd 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 ('
DATE DRILLED 4-30-2013
TIME COMPLETED AM 0 PM ❑
4. WELL LOCATION:
KENANSVILLE COUNTY DUPLIN
113 W SCOTT ST. - HORSEBRANCH
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope [Walley 'Fiat ❑ Ridge ❑Other
LATITUDE 34 0 57 . 35.7800 DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 59 , 42.3700 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: [ 3PS [Topographic map
(location 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
6. WELL DETAILS:
a. TOTAL DEPTH: 210
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO II
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
Submit within 30 days of completion to: Division of Water Quality - Information Processin
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
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Top
Top Bottom
Top Bottom
11. DRILLING LOG
Top
108
110
Bottom
/110
g. WATER ZONES (depth):
Top
Top
Top
7. CASING: Depth
Top 0 Bottom 200
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
114680
Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Thickness/
Diameter Weight Material
Ft. 4 40 PVC
Ft.
Ft.
Material Method
Ft. HOLE PLUG POURED
Ft.
Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 200 Bottom 210 Ft.4 in. .015 in. PVC
Ft. in. in.
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth t - ._ _=Sizes Material _ _ _ _— -_
190 Bottom 218 = F#2-. _ ---
Ft. in. in.
Ft.
Ft.
Formation Description
CLAY
/113 SAND
113
117
125
130
145
147
160
218 /
/117 CLAY
/125 SAND (MED)
/130 ROCK AND SAND
/ 145 SAND AND CLAY
/ 147 ROCK 18" (VERY HARD)
/160 SAND AND CLAY
/218 SAND
/
12. REMARKS:
ROCK
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iN ' i`tM1 TI ON PR. t�C't''}+.=?�t` ;'t ( i
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• 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WIT1-1-15A NCAC 2C,WELL -CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVID D TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL�COITRACTOR
7-3-13
DATE
ttG l � Mt�£j3Ga ` 11, Y
DAVID L REGISTER rcF` ` 4My
PRINTED NAME OF PERSON CONTUC NG THE WELL2
tik
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•JUL '20 +,
Form qvy-1 a
Rev. 2/Gb
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