408605_Well Construction - GW1_20121022

4:08605
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -
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# 217
NC
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Rif
DATE DRILLED 10-01-2012
TIME COMPLETED
4. WELL LOCATION:
CITY: BEULAVILLE COUNTYDUPLIN
AM PM ID
1587 PASTURE BRANCH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley Rf Flat ❑Ridge. ❑Other
LATITUDE 34 ° 51 ' 8.3000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 51 , 56.7000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: [PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
R. L. PICKETT
Owner Name
1587 PASTURE BRANCH ROAD
Street Address
BEULAVILLE NC 28518
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO II
c. WATER LEVEL Below Top of Casing: 13 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): 125 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
•
•
•
•
•
•
0CT172012
Division of Water Quality
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0 Bottom 160
CENTRAL FLES
OWQ/O
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 4 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 160 Bottom 180 Ft.4 in. .015 in. PVC
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 150 Bottom 240
Top Bottom
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /15
15 /16
16 /18
18 /19
19 /80 CLAY
in. in.
in. in.
Size Material
Ft. #2
Ft.
Formation Description
SAND
ROCK 4"
SAND AND CLAY
ROCK 12"
80 /95 SAND
95 / 140
140 /185
185 /187
187 /198
198 /220
220 /240+
BY:
ROCK AND SAND (MED)
SAND (MED)
ROCK AND SAND
SAND (MED-FINE)
SAND AND CLAY
CLAY
1 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 f6 D TO THE WELL OJONNER.
10-10-12
SIGNATURE OF CERTIFIED WLLL 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