404795_Well Construction - GW1_20120425

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# 24971
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigations( Other ❑ (list use)
DATE DRILLED 1-17-2012
4. WELL LOCATION:
LANDFILL ROAD
NC
State
28458
Zip Code
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ROSE HILL COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFlat ['Ridge DOther
LATITUDE 34 0 51 ' 36.5000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 58 , 23.6000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: IGPS [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.)
DUPLIN WINERY
Facility Name Facility ID# (if applicable)
LANQFILL ROAD
Street Address
ROSE HILL
City or Town
BILLY WJLSON
Contact Name
PO BOX 756
Mailing Address
ROSE HILL
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 160
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 37
(Use "+" if Above Top of Casing)
NC 28458
State Zip Code
NC 28458
State Zip Code
YES ❑ NO qI
FT.
-.105
: 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): 100 METHOD OF TEST AIR
: f. DISINFECTION: Type HTH Amount 4 OZ
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 135 Ft. 4 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 135 Bottom 160 Ft. 4 in. .015 in. PVC
Top
Top
Bottom
Bottom
Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top 130 Bottom 180 Ft. #2
Top Bottom Ft.
Top
• 11. DRILLING LOG
: Top Bottom
0
10
20
62
63
79
80
93
115
130
140
/10
/ 20
/ 62
/ 63
/ 79
/ 80
/ 93
/ 115
/ 130
/ 140
/ 160
1• 2. REMARKS:
Bottom Ft.
Formation Description
SAND AND CLAY::
SAND
CLAY
ROCK 1"
CLAY
ROCK 3"
SAND (MED)
SAND AND ROCK
SAND (MED)
SAND AND CLAY
SAND (MED)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECO .BIAS BEEN P'OVIDED T. HE WELL OWNER.
SIG IATURE OF CERTIFIED
4-18-12
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