404798_Well Construction - GW1_20120425

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 4.. 0
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 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigationij Other 0 (list use)
DATE DRILLED 4-12-2012
4. WELL LOCATION:
PINE RIDGE- RIVER LANDING
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
: d.
e.
f.
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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): 150 METHOD OF TEST AIR
DISINFECTION: Type HTH Amount 3 OZ
: g. WATER ZONES (depth):
: Top
: Top
Top
7. CASING:
Top 0
: Top
Top
8. GROUT:
Top 0
Top
Top
9. SCREEN:
Top 85
Top
Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Thickness/
Depth Diameter Weight Material
Bottom 85 Ft. 4 40 PVC
Bottom Ft.
Bottom Ft.
Depth Material Method
Bottom 20 Ft. HOLE PLUG POURED
Bottom Ft.
CITY: WALLACE COUNTY DUPLIN : Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ['Flat ❑ Ridge ❑Other
LATITUDE 34 ° 44 38.0000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 56 , 4.7000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 1W(3PS [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.)
RIVER LANDING
Facility Name
PINE RIDGE
Facility ID# (if applicable)
Street Address
WALLACE NC 28466
City or Town State Zip Code
CHRIS HERRING
Contact Name
PO BOX 1139
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 105
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 14
(Use "+" if Above Top of Casing)
YES ❑ NO qt
FT.
Bottom Ft.
Depth Diameter Slot Size Material
Bottom 105 Ft. 4 in. .015 in. PVC
Bottom Ft. in. in.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 80 Bottom 107 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
105 / 107+ CLAY
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/
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12. REMARKS:
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC HAS BEENRROVIDED TO T E WELL OWNER.
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I, . , y , 4-18-12
SIGNATURE OF CERTIFIED WEL 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
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