404157_Well Construction - GW1_20120416

NONRESIDENTIAL 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
72 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) #2
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ( Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 2-1-2012
4. WELL LOCATION:
JAMES ROAD 28466
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top
CITY: WALLACE COUNTY DUPLIN : Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley VFW ❑ Ridge ❑Other
LATITUDE 34 44 55.8000 „ DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 45 ' 1.8000 " 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. FACILITY (Name of the business where the well is located.)
Facility Name
JAMES ROAD
Facility ID# (if applicable)
Street Address
PIN HOOK
City or Town
JAM I E WALKER
N.0 28466
State Zip Code
Contact Name
153 DAVID WALKER LANE
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 130
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: 48 FT.
(Use "+" if Above Top of Casing)
r.:.,n 4 r;
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 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 110 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 110 Bottom 130 Ft. 4 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
Bottom
Bottom
• 10. SAND/GRAVEL PACK:
Depth
Top 100 Bottom
Size Material
140 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
• Top Bottom Formation Description
0 / 25 SAND
• 25 / 38 CLAY
• 38 / 76 CLAY AND SOFT ROCK
76 / 97 SAND AND CLAY
• 97 / 130 MED SAND AND ROCK
•
130 /140+
: 12. REMARKS:
FINE SAND AND SHELLS
ONR
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ntorrnattol atF O G
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCO'DANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECOR AS BEEN PROVIDED TO THE WELL OWNER.
: SIGNATURE OF CERTIFIED W ilL C 14ITR . ,.,,i, it-, ,LP I 1 Iv/ 1F, !pi,
:CTOR ,-„,---7� DATE: '�
: DAVID L. REGISTER ii 1 J'_�' i 'i'
. PRINTED NAME OF PERSON CUNSTRU I T LL i E
0 I( j K I b ZW2 I il q
r �'
.�, Form GI -lb
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
Y P Rev. 2109
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] -- �---