406917_Well Construction - GW1_20120813

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IAL WELL CONST
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North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL C
1. WELL CONTRACTOR:
DAVID L REGISTER
NTRACTOR CERTIFICATION # 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
( 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 Applicable Box): Residential Water Supply i
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: (check appropriate box)
❑ Slope ❑Valley (7JFIat ❑ Ridge ❑Other
LATITUDE 34 0 45 6.9000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 78 ° 1 ' 45.7000 " DMS OR 7X.XXXXxXxxX DD
Latitude/longitude source: E 3PS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
TITO PONCE
Owner Name
PO BOX 1163
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 ❑ NO Id
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
\\C'
4
6917
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.
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 Size Material
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Top 150 Bottom 183 Ft. 2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /25 CLAY
SAND AND CLAY
25 /45
Formation Description
45 /60 CLAY
60 / 77 SAND AND CLAY
77 /78 ROCK 14"
78 /97 CLAY
97 /107 ROCK AND CLAY
107 /118 CLAY
118 /130 SAND AND CLAY
130 /140 CLAY
140 /149 SAND AND CLAY
149 /152 ROCK AND SAND
152 /175
175 /180
12. REMARKS:
SAND (MED)
ROCK AND SAN 7-
T. f�i `•y •�
I 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
PROV! ED TO THE WELL OWNER.
.
J./frt.-0 7-23-12
SIGNATURE OF CERTIFIED WELL + NTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of Completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/09