384530_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 22314A
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#
OTHER ASSOCIATED PERMIT#(dapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 05/24/10
TIME COMPLETED 05/24/10 AM ❑ PM ❑
4 WELL LOCATION
cITY Kenansville COUNTY duDlin
266 Faison W McGowan Rd
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley fi 'Flat ❑Ridge ❑Other
LATITUDE 34 ° 58 ' 32 80o0 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 78 ° 25 45000
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [3PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Floyd Adams
Owner Name
266 Faison W McGowan Road
Street Address
Kenansville
City or Town
nc 28349
State Zip Code
�)
Area code Phone number
6 WELL DETAILS:
a TOTAL DEPTH: 200
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO gif
c WATER LEVEL Below Top of Casing 26 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 Al R
f. DISINFECTION Type HTH Amount 2 OZ
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
3S 453O
7 CASING: Depth Diameter
Top 0 Bottom 185 Ft 2
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft hole plug
Bottom
Bottom
Bottom
Thickness/
Weight Material
40 PV.
Top Bottom Ft
Top Bottom Ft
9 SCREEN: Depth Diameter
Top 185 Bottom 200 Ft 2 in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK.
Depth
Top 175 Bottom 220
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
a�" v_
0 Method
poured
Slot Size Material
015 in PVC
in
in
Size Material
Ft 2
Ft
Ft
Formation Descnption
0 / 25 SAND
25 /75 CLAY
75 / 90 SAND AND CLAY
90 / 91 ROCK 12"
91 /101 SAND AND CLAY
101 /105 ROCK AND SAND
105 /180 SAND AND CLAY
180 /197 SAND
197 /202 CLAY
202 / 220+ SAND
/
/
12 REMARKS
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mat ot�'n1?t�O�8OG
I DO HEREBY CERTIFY THAIA�SS WEL'WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
C d-J't 06/10/2010
SIGNATURE OF CERTIFIE. WELL 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-la
Rev 2/09