403520_Well Construction - GW1_20120220

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 4 3 !!
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 NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #Qf applicable) #4
S. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural ( Recovery o Injection o
Irrigation❑ Other 0 (list use)
DATE DRILLED 12-02-2011
4. WELL LOCATION:
565 E N EAS LAN I E R ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: CHINQUAPIN CouNTYDUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
p Slope [Walley hifFlat ❑ Ridge ❑Other
LATITUDE 34 ° 49 , 16.7000 DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 43 , 4.7000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: WXPS ['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 LAN IER ROAD
Street Address
CHINQUAPIN NC 28521
City or Town State Zip Code
MIHN VU
Contact Name
565 EN EAS 1,AN I ER ROAD
Mailing Address
CHINQUAPIN NC 28521
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 305
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c. WATER LEVEL Below Top of Casing: 52 FT.
(Use "+" if Above Top of Casing)
: 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 207 Ft. 4 40 PVC
Top 237 Bottom 243 Ft. 4 40 PVC
Top 268 Bottom 280 Ft. 4 80 PVC
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 207 Bottom 237 Ft. 4 in. .015 in. PVC
Top 243 Bottom 268 Ft. 4 in. .015 in. PVC
Top 280 Bottom 305 Ft. 4 in. .015 in. PVC
: 10. SAND/GRAVEL PACK:
Depth
Top 190 Bottom 316 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
168 /178
178 / 181
181 / 191
191 1196
196 / 205
205 / 218
2,18 /233
233 1 239
239 / 252
252 1 260
260 / 265
12. REMARKS:
Size
.117TIN1,-.), H 177t1
FEB 2 0 201?
For )ion Description
SAND AND CLAY
ROCK AND SAND
CLAY
SAND AND CLAY
CLAY
SAND MED FINE
ROCK AND $AND
CLAY
ROCK AND SAND
SAND
ROCK AND SAND-
1
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE_ WITH;
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY_ OF THIS:
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER:
1-24-12
DATE
SIGNATURE OF CERTIFIED WELL CONTRACTOR
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 OW -lb
Rev. 2/09