404796_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 NC
City or Town State
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 24971
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation[] Other 0 (list use)
DATE DRILLED 1-17-2012
4. WELL LOCATION:
LANDFILL ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ROSE HILL COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 0 51 t 36.5000 " DMS OR 3x.xxxxxxxxx DD
0 58 ' 23.6000 " DMS OR 7X.XXXXXXXXX DD
LONGITUDE 77
Latitude/longitude source: BPS ❑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.)
n
: 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 Bottom Ft. in. in.
Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 130 Bottom 180 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
: 160 / 161 ROCK 6"
DUPLIN WINERY .
Facility Name Facility ID# (if applicable)
LANDFILL ROAD
Street Address
ROSE HILL
City or Town
BILLY WILSON
Contact Name
PO BOX 756
Mailing Address
ROSE HILL
City or Town
( -3
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 160
NC 28458
State Zip Code
NC 28458
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: 37
(Use "+" if Above Top of Casing)
FT.
•
•
•
161 / 180+ SAND AND CLAY
/
/
12. REMARKS:
. F anYt L.
l{�;ti W �tr;�•c:'.ri
a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECOi1*t
' • S BEEN PI JVI DED TO T E WELL OWNER.
•i J• 4-18-12
: SIGNATURE OF C RTIFIED LL 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