411209_Well Construction - GW1_20130204

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#or applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Ni
DATE DRILLED 11-28-12
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: ROCKY POINT couNTYPENDER
TERRAPIN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley FiQFlat ❑Ridge ❑Other
LATITUDE 34 = 27 • 23.0000 •• DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 0 50 • 7.1000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 17fopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
WILLIAM MCLEAN
Owner Name
TERRAPIN ROAD
Street Address
ROCKY POINT
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 65
NC 28457
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES d NO ❑
c. WATER LEVEL Below Top of Casing: 4 FT.
(Use •'+" if Above Top of Casing)
d. TOP OF CASING IS 2 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): 25 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
4112O Ei
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0 Bottom 45 Ft. 4
Top Bottom Ft.
Top Bottom Ft.
8. GROUT:. Depth
Top 0 Bottom 20
Top Bottom
Thickness/
Weight Material
40 PVC
Material Method
Ft. HOLE PLUG POURED
Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top45 Bottom65 Ft4 in. .015 in. PVC
Top Bottom
Top Bottom
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 40 Bottom 100 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /15
15 /45
45 /60
60 /100+
12. REMARKS:
Formation Description
SAND (FINE)
ROCK AND SAND (FINE)
SAND (FINE)
SAND (FINE)
EB 0 4 2013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROV)MED TO E WELL QWNER.
14-t12—/ 12-21-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE-N/ELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] JAN L+
Form GW-la
Rev. 2/09