411930_Well Construction - GW1_20130304

NONRESIDENTIAL 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 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 One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
IrrigationE1 Other ❑ (list use)
DATE DRILLED 2-1-2013
4. WELL LOCATION:
CORNER OCT GLORY & SUGAR MAPLE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
: 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 150 Ft. 4
Top
Top
8. GROUT:
Top
0
Top
Top
9. SCREEN:
Top 150
Top
Bottom Ft.
Bottom Ft.
40 PVC
Depth Material Method
Bottom 20 Ft. HOLE PLUG POURED
Bottom Ft.
Bottom Ft.
Depth Diameter Slot Size Material
Bottom 160 Ft. 4 in. .015 in. PVC
Bottom Ft. in. in.
CITY: WALLACE COUNTY DUPLIN : Top Bottom Ft in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley hiFlat ❑Ridge ❑Other
LATITUDE 34 ° 44 , 55.0000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 56 ' 7.2000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: I03PS ❑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
CORNER OCT_ GLORY
Street Address
WALLACE
City or Town
RIVER LANDING
Facility ID# (if applicable)
& SUGAR MAPLE
NC 28466
State Zip Code
Contact Name
CORNER OCT_ GLORY
Mailing Address
WALLACE
City or Town
& SUGAR MAPLE
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 160
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 8
(Use "+" if Above Top of Casing)
NC 28466
State Zip Code
YES ❑ NO 5,1
FT.
10. SAND/GRAVEL PACK:
Depth
Top 145 Bottom
Top
Top
11. DRILLING LOG
: Top
•
•
Size Material
160 Ft. #2
Ft.
Ft.
WATER OUALflY SECTION
INFORMATION PROCESSING UNIT
Bottom Formation Description
0 / 20 SAND
Bottom
Bottom
20 / 80 . CLAY
80 / 87 SAND
87 / 89 ROCK 24"
89 / 107 SAND (MED)
107 / 114 ROCK, SAND AND CLAY
114 / 118 SAND (MED)
118 / 124 ROCK AND SAND
124 / 126 CLAY
126 / 134 SAND (MED)
134 / 142 CLAY
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC990 HAS BEEN PROVID D TO TH WELL pWNER.
2-6-13
SIGNATURE OF CERTIFIED WEri.. CONTRACTOR DATE
: DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTll THWELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
AR An2 -1b1
Rev. 2/09