411929_Well Construction - GW1_20130304

NONRESIDENTIAL 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
411929
: 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
Street Address : g. WATER ZONES (depth):
ROSE HILL NC 28458 : Top Bottom Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
Top Bottom Top Bottom
Area code Phone number
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0 Bottom 170 Ft. 4 .015 PVC
(910 ) 289-3175
OTHER ASSOCIATED PERMIT#(if applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) ; Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationri Other ❑ (list use)
DATE DRILLED 2-4-2013
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
: Top Bottom Ft.
Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
SOUTHERN MAGNOLIA LN.. LOT#414 : Top 170 Bottom 180 Ft. 4 in. .015 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft. in. in.
CITY: WALLACE COUNTY DUPLIN : Top Bottom Ft in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley (Flat ❑Ridge ❑Other
LATITUDE 34 0 46 , 26.5000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 56 ' 25.7000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS ❑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.)
RIVER LANDING
Facility Name Facility ID# (if applicable)
SOUTHERN MAGNOLIA LANE
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top 160 Bottom 180 Ft. #2
Top Bottom Ft. FEB 2 5 ZD
9
Top Bottom Ft.
WA R QUALITY SECTION
11. DRILLING LOG �-1��6 PR00�811� UPI
Top Bottom Formatio�i �i�on
140 / 155 CLAY
155 / 156 ROCK 6"
156 / 180+ SAND (MED)
Street Address /
WALLACE NC 284 /
City or Town State Zip Code
RIVER LANDING
Contact Name /
SOUTHERN MAGNOLIA LANE LOT#414
Mailing Address
WALLACE
City or Town
NC 28466
State Zip Code
{ )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO cif
c. WATER LEVEL Below Top of Casing: 19 FT.
(Use "+" if Above Top of Casing)
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC C 2C, WELL
RECO HAS BEEN OVID Q ,,TO TH7WELL WNER.
NSTRUCTION STANDARDS, AND THAT A COPY OF THIS
SIGNATURE OF CERTIFIED WELL CONTRACTOR
DAVID L. REGISTER
: PRINTED NAME OF PERSON CONSTRUC IN% YI E WELL
2-6-13
DATE
'+ 4
4. Lcy,i,a.
AR 0 2013
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
i;x4 ..