410451_Well Construction - GW1_20130211

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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
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 0 Agricultural if Recovery ❑ Injection ❑
IrrigationE7d Other ❑ (list use)
DATE DRILLED 10-30-12
4. WELL LOCATION:
DOBSON CHAPEL ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: KENANSVILLE
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley (Flat ❑Ridge
LATITUDE 34 0 53 ' 24.4000
: 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 OZ
▪ 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 230 Ft. 4 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 piameter Slot Size Material
Top 230 Bottom 250 Ft. 4 in. .015 in. PVC
Top
COUNTY DUPLIN Top
(check appropriate box)
❑ Other
LONGITUDE 77 O 56 ' 38.8000
" DMS OR 3X.XXXXXXXXX. DD
" DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 103PS ❑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.)
BOWLES BROTHERS. LLC©
Facility Name Facility ID# (if applicable)
DOBSON CHAPEL ROAD
Street Address
KENANSVILLE NC 2834 P
City or Town State Zip Code
STAN BOWLES
Contact Name
607 CURTIS ROAD
Mailing Address
WARSAW NC 28398
City or Town State Zip Code
)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 42
(Use "+" if Above Top of Casing)
NO 51
FT.
•
•
•
Bottom Ft. in. in.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 220 Bottom 260 Ft. #2
Top Bottom Ft.
Top
11. DRILLING LOG
Top Bottom
180/ 203
Bottom
Ft.
Formation Description
CLAY
203 / 211 SAND (FINE)
211 / 213 ROCK 24"
213 / 220 SAND (MED)
220 / 223 SAND AND ROCK
223 / 245 SAND (MED)
245 / 260+
/
/
12. REMARKS:
MED SAND W/SOME CLAY
OEC 0 5 _012
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTthiN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECOR 'HAS BEEN PRO DED T THE WELL WNER! <• 4.4td411/26/12
• SIGNATURE OF CERTIF ED WELL CONTACTOR' "D►'ATE7'
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUGTINGF
410.1
711 LVId
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
43);a° Form GW-1 b