414503_Well Construction - GW1_20130708

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
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 One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation@i Other 0 (list use)
DATE DRILLED 6-10-2013
4. WELL LOCATION:
HWY 11
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: KENANSVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley wifFlat ❑Ridge ❑Other
LATITUDE 34 0 57 + 36.2900 ++ DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 57 + 53.0900 " 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.)
LIBERTY HALL MUSEUM
Facility Name Facility ID# (if applicable)
HWY 11
Street Address
KENANSVILLE NC 28349
City or Town State Zip Code
LIBERTY HAI 1 MUSEUM
Contact Name
409 S MAIN STREET
Mailing Address
KENANSV]I] .E_ NC _ 98349
City or Town State Zip Code
Area code Phone number
6. iAfEL-L-DETAILS:
a. TOTAL DEPTH: 175
b. DOES WELL REPLACE EXISTING WELL? YES Di NO 0
c. WATER LEVEL Below Top of Casing: 57 FT.
(Use "+" if Above Top of Casing)
414503
: 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): 100 METHOD OF TEST AIR
: f. DISINFECTION: Type HTH Amount 4 OZ
: g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0 Bottom 155 Ft. 4
: Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top
Top
Bottom Ft.
Bottom Ft.
9. SCREEN: Depth
Method
POURED
Diameter Slot Size Material
Top 155 Bottom 175 Ft. 4 in.
: Top _Bottom-7 Ft. in.
Top Bottom Ft. in.
.015
: 10. SAND/GRAVEL PACK:
Depth Size
Top 145 Bottom 175 Ft. #2
Top
Top
11. DRILLING LOG
: Top Bottom
Bottom
Bottom
148 / 175
175 /
/
/
/
12. REMARKS:
Ft.
Ft.
in. PVC
n
in.
Material
Formation Description
SAND (MED)
ROCK
e — 1
S f � C ,,, ; ,.. 7 77, 1 F ,_.j
s•
1 DO-NEREBY-CERTIFYT _ __ .. . ASLONSrtiLiCThDJ CC DANCE WJT
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECO' f ,AS BEEN PRIDED TO E WELL OWNER.
eA
6-18-13
•
SIGNATURE OF CERTIFIED WALL 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 Calf-1 b
Rev. 2/09