408230_Well Construction - GW1_20121001

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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
NC 28458
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 One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other ul(Iist use) RUN PLANT
DATE DRILLED 9-11-2012
4. WELL LOCATION:
469 YELLOWCUT ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ROSE HILL COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley hiFlat ❑Ridge ❑Other
LATITUDE 34 50 , 12.4000 ° DMS OR 3x.xxxxxxxxx DD
LONGITUDE 82 ° 2 14.7000 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. FACILITY (Name of the business where the well is located.)
VALLEY PROTEINS
Facility Name Facility ID# (if applicable)
469 YELLOWCUT ROAD
Street Address
ROSE HILL
City or Town
VALLEY PROTEINS
Contact Name
469 YELLOWCUT ROAD
Mailing Address
ROSE HILL
City or Town
Area code Phone number
NC 28458
State Zip Code
NC ?845.8
State Zip Code
6. WELL DETAILS:
a. TOTAL DEPTH: 251
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO pf
c. WATER LEVEL Below Top of Casing: 37 FT.
(Use "+" if Above Top of Casing)
L R,Peqo
: d. TOP OF CASING IS 2.0 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): 300 METHOD OF TEST AI R
: f. DISINFECTION: Type HTH
: g. WATER ZONES (depth):
: Top Bottom Top
: Top Bottom Top
: Top Bottom Top
= 7. CASING: Depth
Top 0 Bottom 200
Amount 4 OZ
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 6 S-10 SS
: Top _ Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
: Top Bottom Ft.
Top Bottom -Ft.
9. SCREEN: Depth
Top 200 Bottom 250
Top Bottom
Top Bottom
Method
POURED
Diameter Slot Size Material
Ft. 6 in. .020 in. SS
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 190 Bottom 260 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
•
11. DRILLING LOG
: Top Bottom
•
13 / 33
: 33 / 50
50 / 62
62 / 63
63 /65
66 / 67
: 67 / 74
Formation Description
SAND AND CLAY
ROCK 14"
SAND (MED)
74 / 76 CLAY
• 76 / 77
77 / 80
12. REMARKS:
•
•
= i' \J E.r ...` 4• tom•' . f 4J.
I • DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDAiNC/TI, r_�
- 15A NC C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF fititS°'-
• RECO D AS BEEN PAOVIDEO TO THE ELL OWNER.
11
ROCK 2"
CLAY
CEP 2 0 2012
9-11-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
i1n C�ISTFR
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