406812_Well Construction - GW1_20120820

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# 203
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply f
DATE DRILLED 6-18-2012
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: ROSE HILL COUNTY DUPLIN
1152 FIRETOWER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley GtFlat ❑ Ridge ❑Other
LATITUDE 34 0 50 i 39.1000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 78 0 0 , 9.0000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: I 3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
DONALD WELLS
Owner Name
1152 FIRETOWER ROAD
Street Address
ROSE HILL NC 28458
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 225
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO lit
c. WATER LEVEL Below Top of Casing: 45 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): 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
•
•
•
•
•
•
•
Top 195
Top
Top
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 205 Ft. 2 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 Diameter Slot Size Material
Top 205 Bottom 225 Ft.2 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Bottom 229
Bottom
Bottom
Size Material
Ft. #2
Ft.
Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 /20 SAND AND CLAY
20 /30
30 /79
82 /101
101 /102
102 /135
135 /157
157 /165
165 /183
SAND
CLAY
ROCK AND SAND
SAND (MED)
ROCK 10"
SAND AND CLAY
SAND (MED)
ROCK AND SAND
CLAY
183 /184 ROCK 6"
184 /200 CLAY
200 /229
SAND (MED)
229 / ROCK
12. REMARKS:
JUN 2, 9 Z012.
I DO HEREBY CERTIFY THAT THIS WELLSWAS COP TRt ED 1N
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OW I R.
6-28-12
SIGNATURE OF CERTIFIED WELI,CCONTRACTOR DATE
DAVID L REGISTER
i�.
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]
AUG 2 0 orm W-1 a
Rev. 2/09