407913_Well Construction - GW1_20121113

NONRESIDENTIAL WELL CONSTRUCTION RECORD
v North Carolina Department of Environment and Natural Resources- Division of Water Quality
w
` ,, ," WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID 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#
NC
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other Fl(Iist use) WAREHOUSE
DATE DRILLED 5-23-2012
4. WELL LOCATION:
FAIR SLICE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley wifFlat ❑Ridge ❑Other
LATITUDE 34 ° 45 , 7.5000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 59 , 37.4000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 3PS ❑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.)
PAUL PHILLIPS WHSE
Facility Name Facility ID# (if applicable)
Street Address
WALLACE NC 28466
City or Town State Zip Code
PAUL PHILLIPS
Contact Name
597 NC 24 & 50
0 P-7
t Y
•r
3
: 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): 125 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
. 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 250 Ft. 4 40 PVC
: Top 250 Bottom 265 Ft. 4 80
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
: Top Bottom
Top Bottom
9. SCREEN: Depth
Top 265 Bottom 285 Ft. 4
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth Size
: Top 250 Bottom 290 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
in. .015 in. PVC
in. in.
in. in.
Material
: Top Bottom Formation Description
167 / 188 ROCK AND SAND (MED FINE)
188 / 192 SAND AND CLAY
192 / 232 CLAY
232 / 235 ROCK AND SAND
235 / 258 SAND
258 / 261 ROCK 3 ;(HARD)`
261 / 290+ SAND (MED)
Mailing Address
KENANSVILLE NC 28349
City or Town State Zip Code
( -)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 285
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
YES ❑ NO qt
FT.
12. REMARKS:
NOV I 3 2012 s
I DO HEREBY CERTIFY THAT THIS WELL WAS ci 'f RUCTED IN ACCORDANCE WIT
• 15A NCAC 2C, WELL CONSTRUCTION STANDAR R D THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6-18-12
SIGNATURE OF CERTIFIED 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-1 b
Rev. 2/09
4