414688_Well Construction - GW1_20130722

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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#(it applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑•
Industrial/Commercial 0 Agricultural 61 Recovery D Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4-24-2013
4. WELL LOCATION:
620 VEACHS MILL ROAD
_(Street -Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WARSAW COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 5/Flat ❑Ridge ❑Other
LATITUDE 35 ° 3 , 27.2000 „DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 58 , 43.6000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 3PS ['Topographic 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 )
BOWL ES BROTHERS
Facility Name Facility ID# (if applicable)
620 VEACHS MJLL ROAD
Street Address
WARSAW NC 2$
City or Town State Zip Code
BOWLES BROTHERS
Contact Name
620 VEACHS MILL ROAD
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO tl
c. WATER LEVEL Below Top of Casing: 9 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
i•4-888
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): 150 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 245 Ft. 4 40 PVC
: Top Bottom Ft.
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 Material
Top 245 Bottom 265 Ft. 4 in. .015 in. PVC
: Top Bottom Ft. _ _ In. -
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
: Top 230 Bottom 270
Top
Top
11. DRILLING LOG
Top Bottom
•
•
• 0 / 46
/47
4 / 69
. fi9 / 73
85
85 / 95
5 /13
132 / 133
Size Material
Ft. #2
Bottom Ft.
Bottom Ft.
133 / 160
• 160 / 205
JUL(h /� 1
WATER QUALM' SECTION
ForrlitORA
t i 1 tPROC rt�ti;�tri.=.. irS'1 -. R
SAND
ROCK 8"
SAND •
BOCK AND SANn
$AND
CLAY
SAND (MED)
CLAY
SAND (MED)
CLAY
• ▪ 205 /2Q9 SAND (MED)
12. REMARKS:
I D0 HEREBY CERTIFY THAT THIS_WE L srt
• 15A NCAC 2C, WELL CONSTRUCTION) T,,NDARD
• RECORD HAS BEEN PROVIDED TO T I IELL
SIGNATURE OF CERTIFIED
• DAV1
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 7.: [phone]
Form GW-lb
Rev. 2/09