404158_Well Construction - GW1_20120416

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quali
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
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #1
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural fit Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 2-1-2012
4. WELL LOCATION:
JAMES ROAD 28466
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley (Flat ❑ Ridge ❑Other
LATITUDE 34 0 44 , 55.9000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77
0 45 , 1.7000 DMS OR 7X.XXXXXXXXX DD
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.)
Facility Name
JAMES ROAD
Street Address
PIN HOOK
City or Town
JAMIE WALKER
Contact Name
153 DAVID WALKER LANE
Facility lD# (if applicable)
NC 28466
State Zip Code
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 275
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 55
(Use "+" if Above Top of Casing)
ni
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): 30 METHOD OF TEST AIR
: f. DISINFECTION: Type HTH Amount 4 QZ
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 230 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
: Top 230 . Bottom 275
Top Bottom
Top Bottom
: 10. SAND/GRAVEL PACK:
Depth Size Material
Bottom 292 Ft. #1
Top 220
Top
: Top
: 11. DRILLING LOG
Top Bottom
0 /25
•
25 / 38
38 / 76
76 / 96
96 / 120
120 / 145
145 / 155
155 / 168
168 /174
174 / 180
180 / 203
12. REMARKS:
Diameter Slot Size Material
Ft. 4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
Bottom Ft.
Bottom Ft.
Formation Description
SAND
CLAY
CLAY AND SOFT ROCK
SAND AND CLAY
SAND AND ROCK
SAND AND SHELLS
SAND AND CLAY
CLAY
SAND AND CLAY
SAND (MED)
SAND Amnic Y. %
n
��.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUQT.E � C RI7A Tv' I'm
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANT AT COFX prj l ,
RECORD BEEN PROVIDED TO THE WELL OWNER.
i.%:vA.. . 3-26-12
SIGNATURE OF CERTIFIED (ELL ,C-ONTRA.CTO.R______._,,, __DATE
• 0 r ram' (n 1 (R i,' p 1� f r-�
DAVID L. REGISTER � �...-� 11, i ��-, r•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL J 1
• ''dLi
'i APR 162012 ii s
Submit within 30 days of completion to: Division of Water Quality- Information Prod • For-r �' w-1b
� � essing, Rev. 209
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] ` - r�
YES ❑ NO 51
FT.