413944_Well Construction - GW1_20130610

N
ON RESIDENTIAL 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
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 One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural Recovery ❑ Injection ❑
IrrigationD Other ❑ (list use)
DATE DRILLED 5-14-2013
4. WELL LOCATION:
PASTURE BRANCH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ROSE HILL COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley iitFlat ❑ Ridge Z Other
LATITUDE 34 a 50 ' 13.6000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 54 , 30.5800 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source:PS :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.)
J,.F.(BUDIRIVENBARK
Facility Name Facility ID# (if applicable)
PASTURE BRANCH ROAD
Street Address
ROSE HILL
NC
City or Town State
J_F_(BUD)RIVENBARK
Contact Name
965 OLD FOLKSTONE
Mailing Address
SNEADS FERRY
City or Town
28458
Zip Code
NC 28460
State Zip Code
Area code Phone number
6. WELL -DETAILS:._.
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 66 FT.
(Use "+" if Above Top of Casing)
1 3 9. 4
: 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): 125 METHOD OF TEST AIR
: f. DISINFECTION: Type HTH Amount 4 07
: g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter
Top 0 Bottom 250 Ft. 4
: Top 250 Bottom 280 Ft. 4 80 PVC
Top Bottom Ft.
Weight Material
40 PVC
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
•
Top 270
Top
• Top
11. DRILLING LOG
: Top Bottom
Top Bottom Ft.
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size
Top 280 Bottom 300 Ft 4 in. .015
:Top Bottom Ft. in.
Top Bottom Ft. in. in.
1• 0. SAND/GRAVEL PACK:
Depth Size
Bottom 300 Ft. #2
Bottom
Bottom
206 / 207
207 / 217
217 /219
219 / 272
272 / 304
304 /
12. REMARKS:
Ft.
Ft.
Material
in. PVC
in.
Material
Formation Description
ROCK 10"
SAND AND CLAY
SAND
CLAY
SAND (MED)
ROCK
.... � # :ii
+, l l
VON PROCESSING, uNr
1 DO HEREBY CERTIFY THAT THIS WELL -WAS CONSTRUCTED IN ACCORDANCE lV1TH
15ANC
• RECO
C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
S BEEN PRO DED TO WE I OWNER.
ice' s ®y c
5-30-13
SIGNATURE OF CERTIFIED WELL CC TRACTOR DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09