389081_Well Construction - GW1_20101112

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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 PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industnal/Commercial ❑ Agncultural Ed Recovery ❑ Injection ❑
Irngation❑ Other Waist use) metal recvlcina yard
DATE DRILLED 07/2 1 /10
4. WELL LOCATION '
DuDlin
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
cITY Kenansville couNTY duDlin
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ij1fFlat ❑Ridge ❑Other
LATITUDE 34 45 3 5000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 78 ° 0 13 8000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source 3PS []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 )
Paul Phillips
Facility Name
RAII ROAD STRFFT
Street Address
WAl l ACF
City or Town
PAUI PHII l IPS
Contact Name
�15(17NCHWY248r50
Mailing Address
r KFNANSVII 1 F
"0 City or Town
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH: 268
Facility ID# (if applicable)
b DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing 62
(Use "+" if Above Top of Casing)
NC 28466
State Zip Code
NC 2R34c)
State Zip Code
YES ❑ NO qI
FT
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
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) 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
7 CASING: Depth
Top 0 Bottom 248
Top Bottom
Top Bottom
8 GROUT Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft PVC
Ft
Ft
Material
Ft HOLE PLUG
Ft
Ft
9. SCREEN. Depth Diameter
Top 248 Bottom
Top Bottom Ft in in
Top Bottom
Method
POURED
Slot Size Material
268 Ft 4 in 015 in PVC
10 SAND/GRAVEL PACK:
Depth
Top 240 Bottom 268
Ft m in
Size
Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 12
12 / 16
16 / 35
35 / 36
36 / 82
82 / 85
85 / 110
110 / 122
122 / 140
140 / 145
145 / 155
12. REMARKS
Material
GRAVEL
Formation Descnption
SAND AND CLAY
SAND
CLAY
ROCK 12"
SAND AND CLAY
ROCK AND SAND
SAND
ROCK AND SAND
SAND
SAND AND CLAY
SAND
c v n
I DO HEREBY CERTIFY THAT THIS WELL WAS CpHS1,T``RiUC�TEDNN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDAR}}jj ,.i4ND A A LLbPp75F THIS
RECC,RD HAS BEEN PROVADED)t THE WELL OWNER
OWLS : (QC>tlb'•ti,oi 11/8/10
SIGNATURE OF CERTIFIED WELL CONTRACTQRU ' '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]
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