411490_Well Construction - GW1_20130211

RESIDENTIAL 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
NC 28458
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 227
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 1-17-2013
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: WALLACE
COUNTY DUPLIN
5763 S US HWY 117
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley giFlat ❑ Ridge ❑Other
LATITUDE 34 ° 43 ' 21.9000 DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 5= 15.0000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
CAROLYN KALER
Owner Name
5763 S US 117
•
•
•
•
•
•
•
•
•
•
•
•
.
•
•
•
•
•
•
•
.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Street Address
WALLACE NC 28466
City or Town State Zip Code :
(252 ) 341-4310
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 143
b. DOES WELL REPLACE EXISTING WELL? YES lit NO ❑
c. WATER LEVEL Below Top of Casing: 13 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): 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
g. WATER ZONES (depth) :
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0 Bottom 133
Top Bottom
Top Bottom
Diameter
Ft. 2
Ft.
Ft.
4i1490
Bottom
Bottom
Bottom
Thickness/
Weight Material
40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 133 Bottom 143 Ft.2 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. - in. in.
10. SAND/GRAVEL PACK:
Depth
Top 130 Bottom 143
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /38
38 /57
57 /58
58 /75
75 /98
98 /99
99 /143
143 /
/
12. REMARKS:
Size Material
Ft. #2
Ft.
Ft.
Formation. Description
SAND
CLAY
ROCK 12"
SAND AND CLAY
CLAY
ROCK
SAND (MED)
ROCK
RECEIVED
Information Processing Unit
DWQ/BOG
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
PROVED TO TH WELL OWNER_
SIGNATURE OF CERTIFIED WEL`CONTF ACT(R !DATE
DAVID L REGISTER t 41 CCP 11 2013
PRINTED NAME OF PERSON CONSTRUCTING`; T WELL
GW-la
Rev. 2/09