413397_Well Construction - GW1_20130513

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 28458
State Zip Code
OTHER ASSOCIATED PERMli#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply g4r
DATE DRILLED 4-11 -13
TIME COMPLETED AM 0 PM
4. WELL LOCATION:
CITY: 'WALLACE COUNTY DUPLIN
1947 CYPRESS CREEK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope OValley Et Flat El Ridge ClOther
LATITUDE 34 0 43 , 30.4536 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 o41 , 28.9000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: E&PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
LOUIS TURNER
Owner Name
363 TURKEY POINT ROAD
Street Address
SNEADS FERRY
City or Town
910 ) 333-7450
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
NC 28460
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 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): 10 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0 Bottom 280
Top Bottom Ft.
Top Bottom Ft.
A 1 IF.) 0 n
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 2 40 PVC
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 280 Bottom 300
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
Ft.2 in. .015 in. PVC
10. SAND/GRAVEL PACK:
Depth
Top 270 Bottom 300
Top Bottom Ft.
Top Bottom Ft.
Size Material
Ft. #2
11. DRILLING LOG
Top Bottom
241 /271
271 /274
274 /279
279 /280
280 / 300+
12. REMARKS:
Formation Description
HARD SAND (MED FINE)
ROCK 40"
SAND (MED FINE)
ROCK 6"
ROCK AND SAND (MED FINE)
MAY -3 2013
1,111A.r'D
rar-ff-' PI,'
MAY 3 2013 J
RY:
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
PROyfp ED TO THE WELL OWNER.
\--1
SIGNATURE OF CERTIFIED WELL C
DAVID L REGISTER
cA.A.M 4-30-13
NTRACTOR DATE
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-la
Rev. 2/09