414220_Well Construction - GW1_20130617

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
DATE DRILLED 6-5-2013
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: KENANSVILLE COUNTY DUPLIN
HWY 11
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley EiFlat D Ridge DOther
LATITUDE 34 ° 55
LONGITUDE 77 ° 58
33.1000
53.2600
" DMS OR 3x.xxxxxxxxx DD
" 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
DAVID CHESTNUTT
•
.
•
•
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 95 Ft. 2
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
\iN)
422O
Thickness/
Weight Material
40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 95 Bottom 105
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 90 Bottom 105
Top Bottom
Top Bottom
11. DRILLING LOG
Top
0
Bottom
/20
20
40
58 /83
83
90
105
Method
POURED
Diameter Slot Size Material
Ft.2 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. #2
Ft.
Ft.
Formation Description
SAND
/ 40 SAND, CLAY AND SHELLS
/58 SAND AND CLAY
CLAY
/90 ROCK AND SAND
/105 SAND (MED)
/ CLAY
/
Owner Name /
459 HAM I LTO N ROAD /
Street Address /
MAGNOLIA NC 28453 = /
City or Town State Zip Code : /
( ) /
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 105
b. DOES WELL REPLACE EXISTING WELL? YES C ' NO D
c. WATER LEVEL Below Top of Casing: 53 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): 20 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
12. REMARKS: &T ER QUALM' SECTIO
/`INFORMATION PROCESSING UNIT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRODED TO THE WELL OWNER.
6-6-13
SIGNATURE OF CERTIFIWELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-1 a
Rev. 2/09