403522_Well Construction - GW1_20120220

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NONRESIDENTIAL WELL CONSTRUCTION RECORD 4 0 3
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
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
State
28458
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #3
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural pc Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 1 1-22-2011
4. WELL LOCATION:
565 ENEAS LANIER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN couNTYDUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
['Slope ❑Valley itFlat D Ridge ❑Other
LATITUDE 34 ° 49 , 15.6000 DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 '43 , 4.8000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 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.)
PINE NEEDLE FARMS
Facility Name Facility ID# (if applicable)
565 ENEAS LANIER ROAD
Street Address
CHINQUAPIN NC 28521
City or Town State Zip Code
MIHN VU
Contact Name
565 ENEAS LANIER ROAD
Mailing Address
CHINQUAPIN
City or Town
)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 310
NC 28521
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 52
(Use "+" if Above Top of Casing)
NO El
FT.
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): 35 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 210 Ft. 4 40 PVC
Top 235 Bottom 245 Ft. 4 40 PVC
Top 265 Bottom 280 Ft. 4 80 PVC
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 210 Bottom 235 Ft. 4 in. .015 in. PVC
Top 245 Bottom 265 Ft. 4 in. .015 in. PVC
Top 280 Bottom 310 Ft. 4 s in. .015 in. PVC
1▪ 0. SAND/GRAVEL PACK:
Depth l ize a erl
P
To 200 Bottom 320 Ft. #ilrn � I k ,--1 \ \ \
FEBjj
Top Bottom Ft.1 I
Top Bottom Ft. ;\ M 2 0 ZtVL
016
:▪ it DRILLING LOG
: Top Bottom
0 110
•• 10 /20
20 / 37
37 / 44
44 / 60
60 / 73
73 /78
ormation Description______---
SAND —
SAND A N D CLAY
CLAY
MARL AND ROCK
ROCK AND CLAY
CLAY
ROCK AND CLAY
78 / 85 CLAY
85 / 110 SAND MED FINE
110 / 120 SAND AND CLAY
120 / 134
12. REMARKS:
SAND MED FINE
i
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC l - r HAS BEE PROVIDED TO TH,WELL QWNER.
• et,t1. `
•
SIGNATURE OF CERTIFIED WEL
•
: DAVID L. REGISTER
1-24-12
CONTRACTOR DATE
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 27693-1615Phone [phone]
Form GW-1 b
Rev. 2/09