384532_Well Construction - GW1_20100619

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 NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 24033
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID Of applicable)
3 WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industnal/Commercial 0 Agricultural 6 Recovery 0 Injection ❑
Irrigationi Other 0 (list use)
DATE DRILLED 04/30/10
4. WELL LOCATION.
309 Brooks Quinn Road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
crry Magnolia COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope DValley IOW ❑Ridge ❑Other
LATITUDE 34 ° 53 . 59 2000 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 78 1 37 2000 " 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 )
Oliver & Wendv Fvans
Facility Name Facility ID# (if applicable)
309 Brooks Outnn Road
Street Address
Maanolia NC 28453
City or Town State Zip Code
Oliver & Wendy Fvans
Contact Name
309 Brooks Ouinn Rnad
Mailing Address
Maanolia NC: 28453
City or Town State Zip Code
�)
Area code Phone number
6 WELL DETAILS:
a TOTAL DEPTH: 235
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO 51
c WATER LEVEL Below Top of Casing 17
(Use "+" if Above Top of Casing)
FT
3E 4,532
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 4 aZ
g•
WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top
*t •.'
Thick
7. CASING. Depth Diameter Weight \QNIla
Top 0 Bottom 215 Ft 40 PVC
Top Bottom Ft
Top Bottom Ft
B
8 GROUT Depth Matenal Method
Top 0 Bottom 20 Ft hole plug poured
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter Slot Size Material
Top 215 Bottom 235 Ft 4 in 015 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK -
Depth Size Material
Top 205 Bottom 240 Ft 2 GRAVEL
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 8 sand
8 / 47 sand and clay
47 / 53 rock. sand . and clay
53 / 120 sand and clay
120 / 121 rock 10"
121 / 132 sand
132 / 138
rock 18"
138 / 139 hand
139 / 155 sand and clay
155 / 185
185 /240+
12 REMARKS
edl m
-$1
I DO HEREBY CERTIFY THAT THIS WELL WAS ON T fl�riQ •
15A NCAC 2C WELL CONSTRUCTION STANL1 t,i �o? •••
RECORDk4AS BEEN PROVIDED TO THE WELL OWNER V
� 7a l
SIGNATURE OF CERTIFIED
Untt
DANCE WITH
F THIS
06/10/10
ELL 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]
Form GW-lb
Rev 2/09