411559_Well Construction - GW1_20130211

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 NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Of applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural sr Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 1-8-2013
4. WELL LOCATION:
HUFFMANTOWN ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: RICHLANDS COUNTYONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
['Slope ['Valley jFlat ❑Ridge ❑Other
LATITUDE 34 ° 57 • 7.0000 " DMS OR 3X.XXX (XXXX ( DD
LONGITUDE 77 ° 33 • 29.2000 ^ DMS OR 7X.XXXXXXXXX DD
LatitudeAongltude source: BPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS)
5. FACILITY (Name of the business where the well is located.)
A ,I HI IFFMAN
Facility Name Facility ID# (if applicable)
HIIFFMANTOWN ROAD
Street Address
RICHI ANDS
City or Town
A .I HI IFFMAN
Contact Name
612 BARRFE ROAD
Mailing Address
RICHI ANDS
City or Town
NC 28574
State Zip Code
NC 28574
State Zip Code
! )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES El NO 0
c. WATER LEVEL Below Top of Casing: 71 FT.
(Use "+" if Above Top of Casing)
4t1559
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): 35 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 250 Ft. 4 PVC
Top 250 Bottom 260 Ft. 4 80 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
Top 260 Bottom 300
Top Bottom
Top Bottom
Diameter
FL 4 in.
Ft. in.
Ft. in.
10. SAND/GRAVEL PACK:
Depth
Top 250 Bottom 315
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 / 18
18 / 20
20 / 38
38 / 43
3 /50
50 / 53
53 / 62
62 _/ 63
63 / 83
83 / 112
112
12. REMARKS:
Size
Ft. #1
Ft.
Ft.
Slot Size
.015 in.
in.
in.
Material
PVC
h2013
IrorrnatIon Processing Unit
OWO/BOG
Formation Description.
CLAY
SAND
MARL AND CLAY
MARL AND ROCK
MP RL
ROCK 3'
(MARL AND CLAY
ROCK 4"
CLAY
ROCK AND SAND
ROCK AND CLAY
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN)C4'I�RDANCE WIT
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A OF THIS
RECORp'Bf�Stt BEEN ROVIDEC�TO THE ELL 9WNER
tiZU` ,a... a. 1 34-13
SIGNATURE OF CERTIFIED WELL CONTRACTOR CA' ' DATE
DAVID L. RFGISTFR
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-1 b
Rev. 2/09