403549_Well Construction - GW1_20120220

RESIDENTIAL 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
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. WELL USE (Check Applicable Box): Residential Water Supply Mi
• DATE DRILLED 01-10-2012
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: FAISON COUNTY DUPLIN
1890NNC50&US117HWY
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley wiFlat ['Ridge
LATITUDE 35
LONGITUDE 78 ° 7
°6
(check appropriate box)
❑Other
25.0000 DMS OR 3X.XxxXXXXXX DD
57.0000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: (GPS
(location of well must be shown on a
this form if not using GPS)
5. WELL OWNER
BARRY NEWHARD
❑Topographic map
USGS topo map andattached to
Owner Name
1890N NC50&US 117HWY
Street Address
FAISON
City or Town
1 )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 280
NC 28341
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO it
c. WATER LEVEL Below Top of Casing: 50 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): 100 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
•
•
•
•
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top O Bottom 250 R. 4
Top 250 Bottom 265 Ft. 4
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 265 Bottom 280
Top Bottom Ft. in. in.
Top Bottom
Bottom
Bottom
Bottom
Thickness/
Weight
40
80
Material
Ft. HOLE PLUG
Ft.
Ft.
Material
PVC
PVC
Method
POURED
Diameter Slot Size Material
Ft.4 in. .015 in. PVC
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 250 Bottom 305 Ft. #2
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /10
10 /25
25 /70
70 /80
80 /140
140 /215
215 /240
240 /241
241 /265
265 /305+
/
/
12. REMARKS:
Ft.
Ft.
Material
Formation Description
CLAY
SAND AND CLAY
CLAY
SAND AND CLAY
SAND MED
SAND AND CLAY
CLAY
ROCK SOFT
CLAY
SAND COARSE
Jt J�✓/tJ
Ike
nlob, e r
\,
FEB I 6'c'{,'„ql,.:\
WATER QUAUTY
41 EORMATIOW PROCESSING VSIT
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
PROV D TO TH, WELL OWNER.
SIGNATURE OF CERTIFIED WE
DAVID L REGISTER
2-1-12
CONTRACTOR DATE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/09