411937_Well Construction - GW1_20130304

IV!ONRESIDENTIAL 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
City or Town
NC 28458
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 One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationrd Other ❑ (list use)
DATE DRILLED 1-31-2013
4. WELL LOCATION:
RED FOX RUN
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Valley p.'Flat ❑Ridge ❑Other
LATITUDE 34 ° 45 18.4000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 55 ' 48.7000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: I(GPS ❑Topographic 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.)
RIVER LANDING
Facility Name Facility ID# (if applicable)
RED FOX RUN
Street Address
WALLACE NC 28466
City or Town State Zip Code
RIVER LANDING
Contact Name
RED FOX RUN
Mailing Address
WALLACE NC 28466
City or Town State Zip Code
(_
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 93
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: 16 FT.
(Use "+" if Above Top of Casing)
L CONTRACTOR
A 11 CI0
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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
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 83 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.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 83 Bottom 93 Ft. 4 in. .015 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 80 Bottom
Top Bottom
Top Bottom
11. DRILLING LOG
: Top Bottom
• 0 / 20
20 /78
78 / 82
82 / 93
•
• 93 /
•
•
/
12. REMARKS:
Size Material
93 Ft. #2
Ft.
Ft.
FFP 9 o n n
WTE ` QUALI :Y SECTION
CNA, ►� �i �' eSSING UNIT
SAND
CLAY
ROCK AND SAND
SAND (MED)
ROCK
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECHAS BEEN ' ROVIED TO TH . WELL OWNER.
• SIGNATURE OF CERTIFIED W
: DAVID L. REGISTER
2-6-13
DATE
MAR 6 4 2013
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