406918_Well Construction - GW1_20120813

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L WELL CONSTRUCTION
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North Carolina Departrnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACT
1. WELL CONTRACTOR:
DAVID L REGISTER
*
R CERTEFICATION # 2314A
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
9.10) 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 Pc
DATE DRILLED 7-19-2012
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: WALLACE
CORNWALLIS ROAD
COUNTY DUPLIN
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley GifFlat ❑ Ridge
LATITUDE 34 ° 45 • 6.9000
LONGITUDE 78 ° 1 , 45.7000
(check appropriate box)
❑ Other
" DMS OR 3x.xxxxxxxxx DD
Latitude/longitude source: WASPS
(location of well must be shown on a
this form if not using GPS)
5. WELL OWNER
TITO PONCE
Owner Name
PO BOX 1163
" DMS OR 7x.xxxxxxxxx DD
['Topographic map
USGS topo map andattached to
Street Address
WALLACE NC 28466
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Rf
c. WATER LEVEL Below Top of Casing: 45 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): 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
4069
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 160 Ft. 2 .40 . PVC
▪ Top Bottom Ft.
Top Bottom Ft.
•
•
•
.
Top 150
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 160 Bottom 180 Ft.2 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Bottom 183
Size Material
Ft. 2
Top Bottom Ft.
.
• Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
180 / 183+ SAND AND CLAY
/
12. REMARKS:
AUG 9 g 2012
•
..t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS1"a
ACCORDANCE WITH 15A NCAC 2C, WELL COI S UCTf,ON ->
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
• PROVIDED TO THE WELL OWNER.
x
7-23-12
SIGNATURE OF CERTIFIED WELL ONTRACTOR 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