413396_Well Construction - GW1_20130513

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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 -Cif applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply gr
DATE DRILLED 4-11-13
28458
Zip Code
TIME COMPLETED AM El PM 1:1
4. WELL LOCATION:
CITY: WALLACE COUNTY DUPLIN
1947 CYPRESS CREEK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
EISlope [Walley bt Flat
LATITUDE 34 ° 43
41
LONGITUDE 77
ID Ridge o Other
30.4536 " DMS OR 3X.XXXXXXXXX DD
, 28.9000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ZbPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
LOUIS TURNER
Owner Name
363 TURKEY POINT ROAD
Street Address
SNEADS FERRY
City or Town
910 ) 333-7450
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
NC 28460
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ID NO 11(
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): 10 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
i
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
• Top 0 Bottom 280 Ft. 2 40 PVC
•
•
• ▪ Top Bottom Ft.
• • Top Bottom Ft.
•
•
•
•
8. GROUT: Depth
• TopO Bottom Top Bottom
•
• Top Bottom
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
9. SCREEN: Depth
Top 280
Top
Top
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
Diameter Slot Size Material
Bottom 300 Ft2
Bottom Ft.
Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth•
Top 270 Bottom 300
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 / 13
13 / 32
32
/ 38
• 38
•
/ 76
76
/ 90
• • 90
•
•
•
•
•
•
/ 103
103
/ 130
130
/ 145
145
in. .015 in. PVC
in. in.
in.
Size Material
Ft. #2
Ft.
Ft.
SAN!?
CLAY
SAND AND SHELLS
MAY — 3 2013
gibaltVicinSECTION
RMAT/ON PROCgSSNO UNiT
MARL AND CLAY
ROCK AND CLAY
CLAY
ROCK AND CLAY
SAND (MED)
/ 160 SAND AND CLAY
• 160 /210 CLAY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
210
228
/ 228 SAND (MED) NO WATER
/229 ROCK 3"
229 / 240 SAND (MED FINE)
240 / 241 ROCK 2"
12. REMARKS:
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MAY 3 2013
I DO HEREBY CERTIFY THAT THIS \f‘ LL WAS CONSTRUCTEDIN
ACCORDANCE WITH 15A NCAC 2C, ELECONSTRUCTION-
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 Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev. 2/09