409463_Well Construction - GW1_20121210

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RESIDENTIAL 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
910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 219
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply If
DATE DRILLED 10-22-2012
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: TEACHEY COUNTY D U P L I N
324 GARLAND KING ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope (Valley Flat ❑ Ridge ❑Other
LATITUDE 34 0 47 , 37.9000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 57 ' 56.6000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: Wir3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
THOMAS DION
Owner Name
324 GARLAND KING ROAD
Street Address
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TEACHEY NC 28464
City or Town State Zip Code :
(910 ) 285-2066
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
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b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R
c. WATER LEVEL Below Top of Casing: 38 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): 25 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
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g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 165 ' Ft. 2 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 165 Bottom 180 Ft.2
Top Bottom Ft
Top Bottom Ft.
in.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size
Top 155 Bottom 187 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Slot Size Material
.015 in. PVC
in.
in.
Material
Top Bottom Formation Description
0 / 10 CLAY
10 /30 SAND
30 /79 SAND AND CLAY
79 /90 ROCK AND SAND
90 /97 SAND AND CLAY
97 / 103 CLAY
103 /115 ROCK AND SAND
115
132
145.
/ 132 SAND (MED)
/ 145 SAND AND CLAY
/ 187 SAND (MED)
187 / ROCK
12. REMARKS:
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO 1f D TO THE WELL OWII,ER.
10-25-12
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]
DEC 1 0 2012
Form GW-1
Rev. 2/09