413401_Well Construction - GW1_20130503

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ESIDENTIAL 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
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)
3. WELL USE (Check Applicable Box): Residential Water Supply L
DATE DRILLED 4-23-13
28458
Zip Code
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: PIN HOOK
COUNTY DUPLIN
LIGHTHOUSE CHURCH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley 'Flat ❑ Ridge DOther
LATITUDE 34 ° 45 , 8.1700 "DMS OR 3x.xxxxxxxXx DD
LONGITUDE 77 ° 48 , 17.9000 " 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. WELL OWNER
ALAN S H O LAR
Owner Name
1146 DEEP BOTTOM ROAD
Street Address
WALLACE NC 28466
City or Town State Zip Code
(319 ) 572-1197
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 247
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Mr
c. WATER LEVEL Below Top of Casing: 40 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): 25 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
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g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
7. CASING: Depth
Top 0 Bottom 234
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
1 0 I 1")
= .2:
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 2 40 PVC
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 237
Bottom 247
Top Bottom
Top Bottom
Ft.2 in. .015 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 225 Bottom 247
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /20
20 /40
40 /57
57 / 58
58 /85
85 /110
110 /125
125 /128
128 /145
145 /158
158 /179
179 /187
187 /198
198 /206
12. REMARKS:
Size Material
Ft. #2
Ft.
Ft.
Formation Description
CLAY
SAND AND CLAY
SAND AND SHELLS
ROCK 2"
CLAY
SAND (MED)
SAND AND CLAY
ROCK AND SAND
SAND AND CLAY
CLAY
SAND ANip,
ROCK A&-S ID:s . �r
SAND Sapr20u
��i
c;
ROCK 1DI'' f�. �, 1D1 3 MktY32O13
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INFORMA 1 tON i UNIT
WATER r LIAM
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 WELL OWNER.
4-30-13
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 QualCi
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09