405999_Well Construction - GW1_20120723

4„.
SMEAVAL WELL CONSTRUCTION RECO
D
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
NC
State
28458
Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMIT*(ii applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 6-5-2012
TIME COMPLETED AM 0 PM ID
4. WELL LOCATION:
CITY: WARSAW COUNTY DUPLIN •
BUCK BRANCH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope OValley rFlat CI Ridge 00ther
LATITUDE 34 58 29.9000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 78 0 0 , 50.1000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
BOWLES BROTHERS
Owner Name
620 VEACHES MILL ROAD
Street Address
WARSAW NC 28398
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 235
b. DOES WELL REPLACE EXISTING WELL? YES ED NO
c. WATER LEVEL Below Top of Casing: 38 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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
Top 210
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0
Top
Top
Bottom 220 Ft. 4
Bottom Ft.
Bottom Ft.
8. GROUT: Depth
Top 0
Top
Top
Bottom 20
Bottom
Bottom
9. SCREEN: Depth
c,
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
40 PVC
Material Method
Ft. HOLE PLUG POURED
Ft.
Ft.
Diameter Slot Size Material
Top 220 Bottom 235 Ft.4
Top Bottom . Ft.
Bottom Ft.
Top
10. SAND/GRAVEL PACK:
Depth
Bottom 235
in.
in.
in.
.015 in. PVC
in.
in.
Size Material
Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /30
30 /40
40 /110
110 /125
125 /133
133 /136
136 /146
146 /148
148 /161
161 /163
163 /170
170 /190
190 /235
235 /
12. REMARKS:
Formation Description
SAND AND CLAY
CLAY
SAND AND CLAY
SAND (MED)
ROCK AND SAND
SAND AND CLAY
SAND (MED)
ROCK 18"
SAND AND CLAY
ROCK AND SAND
SAND AND CLAY
SAND (MED COARSE)
SAND (MED)
SAND AND CLAY
juN
z z JUL 2 3 2012
I DO HEREBY CERTIFY THAT THIS tri4MAtial trONSTRUCTED IN-- - -
ACCORDANCE WITHIVANICAb* WNSTRUCTION
STANDARDS, AND THAT A coFiI4t S RECORD HAS BEEN
PROV DED TO THE WELL OWNER.
I.
46
6-18-12
SI ATURE OF CERTIFIED WELCONTRACTOR DATE
DAVID L REGISTER
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