406919_Well Construction - GW1_20120813

SI
ENTIAL WELL CONSTRUCTION RECO D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2-14A
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
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 ❑ Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
IrrigationEi Other 0 (list use)
DATE DRILLED 12-6-2011
4. WELL LOCATION:
FOUNTAINTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BEULAVILLE couNTYDUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ ValleyitFlat ❑Ridge ❑Other
LATITUDE 34 ° 52 , 16.7000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 42 ' 10.3000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: rGPS ❑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.)
CECIL LANIER
Facility Name Facility ID# (if applicable)
FOUNTAINTOWN ROAD
Street Address
BEULAVILLE
City or Town
CECIL LANIER
Contact Name
809 E BROAD STREET
Mailing Address
City or Town
NC 28518
State Zip Code
l )
Area code Phone number
9. WELL DETAILS:
a. TOTAL DEPTH: 275
State
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES CEO NO ❑
c. WATER LEVEL Below Top of Casing: 26
(Use "+" if Above Top of Casing)
FT.
0 919
: 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): 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
• Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Top
: Top
Top
7. CASING: Depth Diameter
Top 0 Bottom 255 Ft. 2
• Ft.
Ft.
: Top Bottom
Top Bottom
Thickness/
Weight Material
.40 PVC
8. GROUT: Depth . Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
: Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 245
Top
Top
11. DRILLING LOG
: Top Bottom
Diameter Slot Size Material
Top 255 Bottom 275 Ft. 2 in. .015 in. PVC
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Bottom 280
Bottom
Bottom
0 /10
10 / 18
18 / 40
40 / 43
100
100 / 143
143 / 145
14 / 155
155 / 177
177 / 183
183 / 197
12. REMARKS:
in. in.
in. in.
Size
Ft.#1
Ft.
Ft.
Material
Formation Description
SAND ..
CLAY
MARL AND CLAY
MARL AND ROCK
CLAY
MARL
ROCK 2'
MARL
CLAY
SAND (MED). .,
ROCK AND SAN1b tMED)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Irk 'ACe4RDAI CEl1TH`
• 15A NCB 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECOD IIAS BEEN R;ROVIDDr THE WELL OWNER.
SIGNATURE OF CERTIFIE
7-24-12
ELL 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