382538_Well Construction - GW1_20100416

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 9 t
y
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 NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT# 23427
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industnal/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrngationW Other ❑ (list use)
DATE DRILLED 06/09/2010
4. WELL LOCATION
844 JAMES ROAD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley 11Flat ❑Ridge
LATITUDE 34 ° 44 693 0000
LONGITUDE 77 ° 43 809 0000
(check appropriate box)
❑ Other
" DMS OR 3x XXXXXXXXX DD
" DMS OR 7X XXXXXXXXX DD
Latitude/longitude source IXPS [Jropographic 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 )
ROBFRT SHOI AR_`
Facility Name Facility ID# (if applicable)
844 JAMFS ROAD
Street Address
WAI I ACE NC 28466
City or Town State Zip Code
ROBFRT SHOI AR
Contact Name
844 JAMFS ROAD
Mailing Address
WAI I ACE
City or Town
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH 250
b DOES WELL REPLACE EXISTING WELL?
NC 28466
State Zip Code
YES❑ NOL/
c WATER LEVEL Below Top of Casing 30 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 vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 60 METHOD OF TEST AIR
f DISINFECTION: Type HTH Amount 10 pAllAtS
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING
Top 0
Top
Top
Depth
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
220 Ft 4 015 PVC
Ft
Ft
8 GROUT Depth Material Method
Top 0 Bottom 5 Ft CEMENT PUMPED
Top 5 Bottom 20 Ft HOLE PLUG POURED
Top Bottom Ft
9 SCREEN: Depth Diameter
Top 220 Bottom 250
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth Size
Top 230 Bottom 260 Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
• Top Bottom
157 / 165
165 / 167
167 / 170
170 / 173
173 /174
174 / 179
179 / 180
180 / 181
181 / 213
213 / 219
219 / 250
12 REMARKSS,
Slot Size Material
Ft 4 in 015 in PVC
Ft in in
Ft in in
Material
GRAVEL
Formation Descnption
SAND AND CLAY
ROCK 24"
SAND
SOFT ROCK
SAND
CLAY
SAND
SOFT ROCK 16"
CLAY
SAND
ROCKA DN SAND_ _... .
Sand
San a.
Ar( 1 b 2.010
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND Tt1AT f C0 &Y OF-HISSSing Unit
E
• RECOR AS BEEN P OVIDED TO EWL OWNER
t ��� EL DWC/3JC
SIGNATURE OF CERTIFIED W L CONTRACTOR DATE
DAVID L REGISTER
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]
TMS
Form GW-1 b
DEC 0 9 MT
2/09