413587_Well Construction - GW1_20130515

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L 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#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Vi
DATE DRILLED 5-7-2013
TIME COMPLETED AM El PM EI
4. WELL LOCATION:
CITY: ROSE HILL COUNTY DUPLIN
FIRETOWER ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope DValley lifFlat 0 Ridge DOther
LATITUDE 34 o5j , 38.2000 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77
59 , 52.0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: VGPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
DURWOOD PARKER
Owner Name
1346 BROOKS QUINN ROAD
Street Address
ROSE HILL
City or Town
(910 ) 289-0469
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 235
NC 28458
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO if
c. WATER LEVEL Below Top of Casing: 43 FT.
(Use "+" if Above Top of Casing)
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): 30 METHOD OF TEST AIR
Top 210
413'587
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0
Top
Top
Bottom 225
Bottom
Bottom
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Diameter
Ft. 2
Ft.
Ft.
Bottom
Bottom
Bottom
Thickness/
Weight
Material
40 PVC
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
Top 225 Bottom 235 Ft.4
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Bottom 235
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
158 /167
167 /175
175 /185
185
200
217
235
/200
/217
/235
12. REMARKS:
in. .015 in. PVC
in. in.
in. in.
Size Material
Ft. #2
Ft.
Ft.
Formation Description
ROCK AND SAND
SAND
SAND AND CLAY
CLAY
SAND AND CLAY
SAND (MED)
ROCK
rune
-I 0--
6.0
MAY I 5 2013
1,AJATL-R QUAL;TV GECTION
twzar-gfirKrirT..1 PP,C7-CM‘,2UT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO D TO TH WEL OWNE .
5-9-13
SIGNATURE OF CERTIFIED WELL ONTRACTOR DATE
DAVID L REGISTER
f. DISINFECTION: Type HTH Amount 3 OZ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to: Division of Water Quail - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-la
Rev. 2/09