407914_Well Construction - GW1_20121113

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 NC 28458
City or Town 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 Applicable Box): Residential Water Supply filf
DATE DRILLED 6-4-2012
TIME COMPLETED AM ❑ PM 0
4. WELL LOCATION:
CITY: KENANSVILLE COUNTY DUPLIN
RICE LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley Flat ❑ Ridge ❑ Other
LATITUDE 34 ° 58 * 36.4000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 78 ° 0 ' 6.1000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: E 3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
PAUL PHILL®PS
Owner Name
597NC24&50
Street Address
KENANSVILLE NC 28349
City or Town State Zip Code
( J
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 200
b. DOES WELL REPLACE EXISTING WELL? YES NO ❑
c. WATER LEVEL Below Top of Casing: 31 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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
Top 175
Top
Top
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 185 Ft. 4
Top Bottom Ft.
Top Bottom Ft.
fry rl
Bottom
Bottom
Bottom
Thickness/
Weight Material
40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 185
Top
Top
Bottom 200 Ft.4
Bottom Ft.
Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Bottom 205
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 /15
15 /35
35 /73
73 /99
99 /103
103 /119
119 /130
130 /165
165 /175
175 /205
205 /
/
12. REMARKS:
in.
in.
in.
.015 in. PVC
in.
in.
Size Material
Ft. #2
Ft.
Ft.
Formation Description
SAND
SAND AND CLAY
CLAY
SAND (MED)
ROCK AND SAND
SAND (MED)
CLAY
SAND (MED)
SAND AND CLAY
SAND (MED)
ROCK
NOV i 3 2012
44
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
PROVIDED TO THE WELL OWNER.
,44414
SIGNATURE OF CERTIFIED ELL CONTRACTOR
DAVID L REGISTER
6-18-12
DATE
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