406138_Well Construction - GW1_20120702

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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
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other s((list use) ASPHALT PLANT
DATE DRILLED 5-21-2012
4. WELL LOCATION:
HWY 24 PICKETTS HILL
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
d.
•
•
e.
f.
i; 1 17)
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.
YIELD (gpm): 75 METHOD OF TEST AIR
DISINFECTION: Type HTH Amount 4 07
g. WATER ZONES (depth):
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0
: Top
Top
8. GROUT:
Top 0
Top
Top
Thickness/
Diameter Weight Material
Bottom 122 Ft. 4 40 PVC
Bottom Ft.
Bottom Ft.
Depth Material Method
Bottom 20 Ft. HOLE PLUG POURED
Bottom Ft.
Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 122 Bottom 132 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
CITY: KENANSVILLE • COUNTY DUPLIN : Top Bottom Ft. , in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 O 57 18.1000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 54 15.4000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS ❑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.)
ROSEBROTHERS
Facility Name Facility ID# (if applicable)
HWY 24 PICKETTS HILL
Street Address
KENANSVILLE NC 2834r9
City or Town State Zip Code
ROSE BROTHERS
Contact Name
PO BOX 806
Mailing Address
AHOSK1E NC 27910
City or Town State Zip Code
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 132
b. DOES WELL REPLACE EXISTING WELL? YES
c. WATER LEVEL Below Top of Casing: 25
(Use "+" if Above Top of Casing)
NO qi
FT.
10. SAND/GRAVEL PACK:
Depth Size MateritcENE
: Top
Top
Top
11. DRILLING LOG
: Top Bottom
131 / 140+
Bottom Ft.
Bottom Ft.
/
12. REMARKS:
Otinbanatiort
$pri Zeittal
Formation Description
SAND AND CLAY
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC4 HAS BEEN ROVI D TO TH ELL OWNER.
•
= SIGNATURE OF CERTIFIED WEL
DAVID L REGISTER
CONTRACTOR
6-13-12
DATE
= 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
JUL ORV210