413586_Well Construction - GW1_20130515

ESIDENTIAL 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
State
28458
Zip Code
OTHER ASSOCIATED PERMITit(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ffic
DATE DRILLED 5-7-2013
TIME COMPLETED AM 0 PM El
4. WELL LOCATION:
CITY: ROSE HILL COUNTY DUPLIN
FIRETOWER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Valley EtFlat oRidge El Other
LATITUDE 34 c, 51 , 38.2000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 . 59 , 52.0000 ,, DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: (3PS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
DURWOOD PARKER
Owner Name
1346 BROOKS QUINN ROAD
Street Address
ROSE HILL
City or Town
(910 ) 289-0469
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 235
NC 28458
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES EJ NO Pr
c. WATER LEVEL Below Top of Casing: 43 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): 30 METHOD OF TEST AIR
4135,9r,
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 225 Ft. 2 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 225 Bottom 235 Ft.4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 210 Bottom 235
Size
Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 10
10 115
15 / 30
30 / 62
62 / 63
63 / 76
76 / 79
79 / 100
100 / 101
101 /107
107 /120
120 /133
133 /141
141 /158
12. REMARKS:
MAY I 5 2013
WATER QUALM' SECTION
UNIT
SANF)ormation-BaGWROCESSING
E
CLAY
SAND AND CLAY
SAND
ROCK 3"
CLAY
ROCK AND CLAY
SAND (MED)
ROCK 3"
SAND (MED)
SAND AND CLAY
CLAY
ROCK AND SAND
SAND (MED)
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
PRO ED TO THE WELL OWNER.
5-9-13
SIGNATURE OF CERTIFIED WEL ONTRACTOR DATE
DAVID L REGISTER
f. DISINFECTION: Type HTH Amount 3 OZ
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