413945_Well Construction - GW1_20130610

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#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Ivf
DATE DRILLED 5-21-2013
TIME COMPLETED - AM ❑ PM ❑
4. WELL LOCATION:
CITY: WATHA
COUNTY PENDER
202 SWANN LAKE CIRCLE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope °Valley /Flat ❑Ridge ❑Other
LATITUDE 34 ° 40 ' 52.1300 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ^ 56 • 38.2100 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VOPS Dropographic map
(location of well must be shown on a USGS topo map andattached to .
this form if not using GPS)
5. WELL OWNER
MARGARET HODGES
Owner Name
202 SWANN LAKE CIRCLE
Street Address
WATHA
City or Town
NC 28478
State Zip Code
�)
Area code Phone number .
6. WELL DETAILS:
a. TOTAL DEPTH: 202
b. DOES WELL REPLACE EXISTING WELL? YES / NO 0
c. WATER .............................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 (g pm). 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
413945
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 187 Ft, 2 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 187 Bottom 202 Ft.2 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. _ in.
10. SAND/GRAVEL PACK:
Depth
Top 170 Bottom 215 Ft. #2
Top Bottom Ft.
Size Material
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /8
8 /18
18 /19
19 /25
25 /57
57 /89
89 /90
90 /102
102 /112
112 /141
141 /147
147 /161
161 /162
162 /172
12. REMARKS:
Formation Description
CLAY
SAND AND CLAY
ROCK 2"
SAND
CLAY
SAND AND CLAY
ROCK 3"
SAND AND CLAY
ROCK AND SAND
SAND (MED)
ROCK AND SAND
SAND (MED)
ROCK 10"
SAND AND CLAY
I DO HEREBY CERTIFY THAT TH
ACCORDANCE WITH 15A NCAC
STANDARDS, AND THAT A COP
PROVIDED TO THE WELL OWNE
JUN (} 3 Hi3
BY:
5-30-13
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,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09