403418_Well Construction - GW1_20120220

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NCON RESIDENTIAL 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
NC 28458
State Zip Code
: 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
(910 ) 289-3175 : Top Bottom Top Bottom
Area code Phone number
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0 Bottom 208 Ft. 4 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) :Top 233 Bottom 245 Ft. 4 40 PVC
SITE WELL ID #(if applicable) #5 : Top 265 Bottom 280 Ft. 4 80 PVC
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural( Recovery ❑ injection ❑ : Top 0 Bottom 20 Ft. HOLE PLUG POURED
Irrigation❑ Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 11-30-201 1 : Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
565 ENEAS LAN I ER ROAD : Top 208 Bottom 233 Ft. 4 in. .015 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top 245 Bottom 265 Ft. 4 in. .015 in. PVC
CITY: CHINQUAPIN COUNTY D UP LI N : Top 280 . Bottom 310 Ft. 4 in. .015 in. PVC
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope DValley Flat ❑ Ridge ❑Other
LATITUDE 34 0 49 , 17.3000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 43 , 3.4000 ,, 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 forr» if not using GPS)
S. FACILITY (Name of the business where the well is located.)
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top 190 Bottom 330 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
11• . DRILLING LOG
: Top Bottom
Formation Description
PINE NEEDLE FARMS 314 / 330+ CLAY rt�
Facility Name Facility ID# (if applicable) \ `���
�1
565 ENEAS LAN I ER ROAD
Street Address, �s
V e\
CHINQUAPIN NC 28521 / ‘ U 1
City or Town State Zip Code
MIHN VU
Contact Name
565 EN EAS LAN IER 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 ❑ NO [/
c. WATER LEVEL Below Top of Casing: 52 FT.
(Use "+" if Above Top of Casing)
12. REMARKS:
VA \`
*4-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED.IN.ACCORDANCE WrrH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS; AND THAT COPY- OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1-24-12
SIGNATURE OF CERTIFIED WELL 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 OW -lb
Rev. 2/09