413516_Well Construction - GW1_20130514

STATE
Oryt
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 Ft
DATE DRILLED 5-2-2013
TIME COMPLETED AM 0 PM
4. WELL LOCATION:
CITY: IGREENEVERS COUNTY DUPLIN
CLINIC CIRCLE DRIVE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0 Slope OValley EifFlat 0 Ridge 00ther
LATITUDE 34 ° 49 , 43.7000 " DMS OR 3X.XXXXXXXXX DD
56 , 22.8000 " DMS OR 7X.XXXXXXXXX DD
LONGITUDE 77
Latitude/longitude source: V3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. WELL OWNER
NATHAN MURRAY
Owner Name
CLINIC CIRCLE DRIVE
Street Address
ROSE HILL NC 28458
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 27
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Mr
c. WATER LEVEL Below Top of Casing: 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
f. DISINFECTION: Type HTH Amount 3 OZ
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Top 110
Top
Top
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom 115
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Diameter Weight Material
Ft. 2 40 PVC
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 115 Bottom 125
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Bottom 125
Material Method
Ft. HOLE PLUG POURED
Ft.
Ft.
Diameter Slot Size Material
Ft.2 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 / 15
15 / 86
86 / 91
91 /107
107 /114
114 /123
123 / 125+
12. REMARKS:
Size Material
Ft. #2
Ft.
Ft.
Formation Description
SAND
CLAY
ROCK AND SAND
SAND (MED-FINE)
ROCK AND SAND
SAND (MED)
ROCK AND SAND
MAY
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
PROVIDED TO THE WEL OWNER.
tAkoki‘ 5-7-13
SIGNATURE OF CERTIFIED ELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
..Submit within 30 days, of OrtiplOtipn::t0t-.Dii0$1pn of Water Quality '19foiittation:Peoce.s'sing,
1617. Mail Service Center, Raleigh, NC 27099,01r., PhohO t:[phone]
Form GW-1 a
Rev. 2/09