414073_Well Construction - GW1_20130610

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#('rf applicable)
SITE WELL ID #Qf applicable)
3. WELL USE (Check One Box) Monitoring o Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationd Other ❑ (list use)
DATE DRILLED 5-22-2013
4. WELL LOCATION:
STAG PARK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BURGAW couNTYPENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope'❑Valley &lot ❑Ridge ❑Other
LATITUDE 34 ' 33 ' 13.0400 " DMS OR 3X.xxxXX0CXX DD
LONGITUDE 77 ' 51 11.2500 " DMS OR 7x.xxxxjoocxx DD
Latitude/longitude source: 3PS 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.)
JAY MII AM
Facility Name Facility ID# (if applicable)
STAG PARK ROAD
Street Address
RURGAW NC 2R425
City or Town State Zip Code
JAYMIIAM
Contact Name
STAG PARK ROAD
Mailing Address
BI 1RGAW
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 235 - -.
NC 28475
State Zip Code
b. DOES WELL. REPLACE EXISTING WELL? YES ❑ - NO qf..
c. WATER LEVEL Below Top of Casing: 16 FT.
(Use "+" If Above Top of Casing)
ROCK (SOFT)
SAND
CLAY
SAND
414073
tl. TOP OF CASING IS 1 5 FT. Above Land Surface*
*Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)' 80 METHOD OF TEST Al R
f. DISINFECTION: Type HTH Amount 4 07
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 189 Ft. 4 4Q PVC
Top 199 Bottom 210 Ft 4 40 PVC
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
Top 189 Bottom 199 Ft. 4 in. .015 in.
Top 210 Bottom 235 Ft. 4 In. .015 in. PVC
Material
PVC
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK: JUN 0 6 2013
Depth Size Material
Top 180 Bottom 240 Ft. WATttoER QUALITI' S� EOplopy
Top Bottom FLU ` OCESS{NG UNIT
Top Bottom FL - -
11. DRILLING LOG
Top Bottom
Formation Description
0 / 60 SAND (YERY FINE)
60 / 100 SAND AND CLAY (FINE)
100 / 137 SAND (FINE)
137 / 160 SAND AND CLAY
160 / 164 SAND
164 / 167
167 / 175
175 / 186
186 / 196
196 / 205
I DO HEREBY CERTIFY THAT THIS WELL WAS CON '} ED IN ACCORDAW1= H---
15ANCAC2C, WELL CONSTRUCTION STANDARDS, kj114Nre0PY1OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNE
5-31-13
SIGNATURE OF CERTIFIED WELL CONTRACTOR - -... DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1817 (Nail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09