404153_Well Construction - GW1_20120416

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L. REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO., INC.
Well Contractor Company Name
72 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 i( Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 2-9-2012
4. WELL LOCATION:
FOUNTAINTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope DValley wirFlat ❑ Ridge ❑Other
LATITUDE 34 a 50 , 56.1000 "DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 40 ' 23.9000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: WIGPS ❑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.)
Facility Name Facility ID# (if applicable)
FOUNTAINTOWN ROAD
Street Address
NC
City or Town State Zip Code
MICHAEL SHOLAR
Contact Name
14008 MARLEIGH LANE
Mailing Address
C L I FTO N VA 20124
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 258
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q%
c. WATER LEVEL Below Top of Casing: 45 FT.
(Use "+" if Above Top of Casing)
.i0 . ...,»
d. TOP OF CASING IS 1 .5 FT. Above Land S'trfiace
*Top of casing terminated at/or below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 75 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 238 Ft. 4
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
: Top 238 Bottom 258
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 225 Bottom 259
40 PVC
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
Ft. 4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
Size
Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
218 / 224
•
•
•
.
•
•
•
224 / 259+
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12. REMARKS:
Material
Formation Description
SAND AND CLAY
HARD ROCK MED FINE SAND
t
W-ki\9\ IOV1.
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‘ni of atio
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;,. HAS BEEN PROVIDED TO THE WELL OWNER.
i '
3-26-12
SIGNATURE OF CERTIFI WELL CONTRACTOR DATE
: DAVID L. REGISTER
PRINTED NAME OF PERSON DIMS- -RU, TTING THEWWELL.HI) LI- 1 hi
• • u
Submit within 30 days of completion to: Division of Water Quality - Information or-1b
•y tion Process g, APR 1 2O1?i'' 1617 Mail Service Center, Raleigh, NC 27699-161Phone : 919 8Q7-630C1 2,09