388002_Well Construction - GW1_20101007

NONRESIDENTIAL 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
NC 28458
State Zip Code
(910 ) 289-3175
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
Irrigation) Other ❑ (list use)
DATE DRILLED 10/5/10
4 WELL LOCATION:
The Bluffs. Riverlandina
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Wallace COUNTY DuDlin
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 ° 44 ' 6 6000 "DMS OR 3x xxxxxxxxx DD
LONGITUDE 77 56 ' 6 8000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source IMPS ['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 )
David & Brenda I ono
Facility Name
The Bluffs Riverlandina
Street Address
Wallace NC
City or Town
Hi Pane Builders
Contact Name
PO Box 1099
Facility ID# (if applicable)
NC 28466
State Zip Code
Mailing Address
Wallace NC 28466
City or Town State Zip Code
�)
Area code Phone number
6. WELL DETAILS.
a. TOTAL DEPTH: 150
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qt
c. WATER LEVEL Below Top of Casing 23 FT
(Use "+" if Above Top of Casing)
3 46 ""
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 3 07
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
7 CASING Depth
Top 0 Bottom 140 Ft 4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 Ft
Top Bottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Diameter Weight
Material
40 PVC
Material
HOLE PLUG
9. SCREEN. Depth Diameter
Top 140 Bottom 150 Ft 4
Top Bottom
Top Bottom
Method
POURED
Slot Size Material
in 015 in PVC
Ft in in
Ft m in
: 10. SAND/GRAVEL PACK.
Depth Size
Top 135 Bottom 155 Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 25
25/40
40 / 65
: 65 / 80
80 / 94
94 / 103
103 / 115
115 / 119
119 / 130
130 / 153
153 /155+
12 REMARKS'
Material
GRAVEL
Formation Descnption
SAND
CLAY
SAND & CLAY
CLAY
SAND AND CLAY
ROCK & SAND MEDIUM
SAND MEDIUM
CLAY
ROCK AND SAND
SAND MEDIUM COARSE
SAND&CLAY1a7 n
111
OCT 0 7 201n
I DO HEREBY CERTIFY THAT THIS WELL? WAS CONSTRUCTED,IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS4ANDiiTHAiACOPY OF THIS
RECORD HAS BEEN PROVIDEDJO THE WELL OWNER
10/5/10
SIGNATURE OF CERTIFIED KNELL 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
OCTA 4 ��d1 Form GW-lb
1 2/09