411558_Well Construction - GW1_20130211

1. WELL CONTRACTOR:
DAVID REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO.. INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address NC 28458
ROSE HILL
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 MunicipaVPublic 0
Industrial/Commercial ❑ Agricultural j Recovery 0 Injection ❑
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 0Valley ❑Ridge ❑Other
LATITUDE 34 ° 57 ' 7.0000 „ DMS OR 3X.)C00000(XX DD
LONGITUDE 77 33 ' 29.2000 " DMS OR Tao( XXXX DD
Latitude/longitude source: Qf3PS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
A .1 HI 1FFMAN
Facility Name
HI IFFMANTOWN ROAD
Street Address
RICHI ANDS
City or Town
A .I HIIFFMAN
Contact Name
R12 RARRFF ROAD
Mailing Address
RICHI ANDS
City or Town
Facility ID# (if applicable)
NC 2857-4
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 EV NO 0
c. WATER LEVEL Below Top of Casing: 71 FT.
(Use "+" if Above Top of Casing)
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
d. 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): 35 METHOD OF TEST AIR
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 4t__ PVC
Top 250 Bottom 260 Ft. 4 80 _ PVC
Top Bottom Ft.
8. GROUT: Depth Material Method
Topes_ Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top 260 Bottom 300 Ft. 4 in.
Top Bottom Ft. in.
Top Bottom Ft. in.
A?'? 558
Material
.015 in. PVC
in.
in.
10. SAND/GRAVEL PACK: "'" } q'"" r
Depth
Top 250 Bottom 315 Ft. #1Size Wiener rIaY y a
Top Bottom Ft.
rEB (; y1113
Top Bottom Ft. '2U is . in Unii
DWQ/BOG
11. DRILLING LOG
Top Bottom Formation Description
125 / 175 SAND (FINE)
175 /209 CLAY
204 / 210 ROCK 2"
210 / 217 SAND (MEDI
217 / 218 ROCK 3"
218 / 235 SAND AND CLAY
235 / 237 ROCK 24"
237 / 248 SAND (MED FINE)
248 / 288 ROCK AND SAND (FINE) .
288 / 294 SAND (MED FINE) /:
294 / P97 ROCKAND SAND (FIN,Ey'
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A
RECOR¢' SBEEN PRVIDEDT THE LL OWNER.
BDANCE WITH
F THIS
SIGNATURE OF CERTIFIED WELL NTRACTOR ;?i .' DATE
DAVID I RFGISTFR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
FD
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC27699-161, Phone :.[phone]
Form GW-lb
Rev. 2/09