413395_Well Construction - GW1_20130513

NON
ESIDENTIAL 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 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural of Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 4-9-2013
4. WELL LOCATION:
CYPRESS CREEK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: BEULAVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
OSlope 0Valley F'Flat ['Ridge 00ther
LATITUDE 34 052 43.6000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 36 16.7400 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: GPS Dropographic 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.)
SHOLAR ENTERPRISE
Facility Name Facility ID# (if applicable)
CYPRESS CREEK ROAD
Street Address
BEULAVILLE NC 2851-8
City or Town State Zip Code
SHOLAR ENTERPRISE
Contact Name
1465 FOUNTAINTOWN ROAD
Mailing Address
BEULAVILLE
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 200
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Gye
c. WATER LEVEL Below Top of Casing: 17
(Use "+" if Above Top of Casing)
FT.
:Top 170
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
4 1 3 3 9 5
: 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): 100 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
i 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 180 Ft. 4 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
: Top Bottom Ft
Top Bottom Ft.
9. SCREEN: Depth
Top 180 Bottom 200 Ft. 4 in. .015
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Bottom 200 Ft. #2
Method
POURED
Diameter Slot Size Material
in. PVC
in.
0 / 10
10 / 25
• 25 / 47
47 / 51
51 / 60
60 / 70
70 / 100
100 / 140
140 / 152
152 / 170
• 170 / 200+
12. REMARKS:
in.
FormatiorM criPtiti 2013
SAND ,NAIrR c,)UAL1 Y SCTON
CLAYNP7)9M,VP074 PROCESSING Oil
MARL
ROCK 4'
MARL
MARL AND CLAY
CLAY AND ROCK
MARL. CLAY AND ROCK
MARL AND SAND
MARLANDCLAY
VitAREr'
AY 2013
,:t13)1
-61 d
I DO HEREBY CERTIFY THAT THIS WELL Ii4ACONSTRUCTED IN ACCORDANCE WITH
15A NCA C, WELL CONSTRUCTION STANDNRDS
• RECOFR H S BEEN PRO1J DED TO TAIE WELL & NEI)
• -4-tol 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-1 b
Rev. 2/09