405203_Well Construction - GW1_20120521

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
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
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural ( Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4-19-2012
4. WELL LOCATION:
BACK SWAMP ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BEULAVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley elat ❑Ridge ❑Other
LATITUDE 34 0 46 , 38.6000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 40 , 53.1000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS Dropographic 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.)
BRINSON FARMS
Facility Name Facility ID# (if applicable)
BACK SWAMP ROAD
Street Address
R FUUI AV11 I F
City or Town
EDDIE BRINSON
Contact Name
994 LYMAN ROAD
Mailing Address
BEULAVILI F
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 220
b. DOES WELL REPLACE EXISTING WELL?
NG 28518
State Zip Code
NC
State
28518
Zip Code
YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 30
(Use "+" if Above Top of Casing)
FT.
405203
: 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
: 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. 4 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 220 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom .Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 195 Bottom 220 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
200 / 210 MED SAND
210 / 211
211 /217
217 / 218
218 /220+
/
/
/
/
/
12. REMARKS:
ROCK 12"
MED SAND
ROCK 12"
CLAY
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC • - , HAS BEEN P OVI DED THE W LL OWNER.
••
• VA-4 1 2' 5-1-12
SIGNATURE OF CER IED WELL woNTRACTOR DATE
: DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING;` THE 1W,
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
NW 241012
Rev. 2/09