413943_Well Construction - GW1_20130610

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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
City or Town State
910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
28458
Zip Code
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural i Recovery ❑ Injection ❑
IrrigationD Other ❑ (list use)
DATE DRILLED 5-14-2013
4. WELL LOCATION:
PASTURE BRANCH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ROSE HILL COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑Valley 'Flat ❑ Ridge •Z Other
LATITUDE 34 ° 50 ' 13.6000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 54 ' 30.5800 " DMS OR 7x.xxxxxxxxx _DD
Latitude/longitude source: MPS ❑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.)
J_F.(BUDIRIVENBARK
Facility Name Facility ID# (if applicable)
PASTURE BRANCH ROAD
Street Address
ROSE HILL
City or Town
J_F_(BUD)RIVENBARK
Contact Name
965 OLD FOLKSTONE
Mailing Address
SNEADS FERRY
City or Town
_MC C 28458
State Zip Code.
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
NC 28460
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO cif
c. WATER LEVEL Below Top of Casing: 66
(Use "+" if Above Top of Casing)
FT.
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): 125 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
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 250 Ft. 4 40 PVC
Top 250 Bottom 280 Ft. 4 80 PVC
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
: Top
Top
Bottom Ft.
Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Method
POURED
Material
Top 280 Bottom 300 Ft. 4 in. .015 in. PVC
: Top Bottom
Top Bottom
Ft. in. in.
Ft. in. in.
1• 0. SAND/GRAVEL PACK:
Depth Size
: Top 270 Bottom 300 Ft. #2
Top Bottom Ft.
Top
▪ 11. DRILLING LOG
: Top Bottom
•
137 / 156
156 / 157
157 / 162
162 / 163
163 / 167
167 / 170
170 / 181
181 / 188
188 / 194
194 / 198
198 / 206.
12. REMARKS:
Bottom Ft.
Material
Formation Descripllon
SAND (MED) 1�6�3.� i I .r � i
ROCK 12" (HAROr t-1,0 ; K . :,.
SAND (MED)
ROCK 10" (HARD)
SAND (MED)
CLAY
SAND AND CLAY
CLAY
SAND AND CLAY
CLAY
SAND
I DO HEREBY CERTIFY THAT THIS WEE —WAS CONST
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AN
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ED.1N ACCORDANCE .WI
S
• 5-30-13
• SIGNATURE OF CERTIFIED WELL 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 GW-lb
Rev. 2/09