410450_Well Construction - GW1_20130211

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
City or Town
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ( Recovery ❑ Injection ❑
Irrigationii Other 0 (list use)
DATE DRILLED 10-30-12
4. WELL LOCATION:
DOBSON CHAPEL ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: KENANSVILLE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley hiFlat - ❑ Ridge ❑ Other
LATITUDE 34 ° 53 ' 24.4000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 56 , 38.8000 " 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. FACILITY (Name of the business where the well is located.)
BOWLES BROTHERS_ LLG
Facility Name Facility ID# (if applicable)
DOBSON CHAPEL ROAD
Street Address
KENANSVILLE NC 28349
City or Town State Zip Code
STAN BOWLES
Contact Name
607 CU RTI S ROAD
Mailing Address
WARSAW NC 28398
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO Gil
c. WATER LEVEL Below Top of Casing: 42 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): 125 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 230 Ft. 4 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
: Top Bottom Ft.
Top Bottom Ft.
r; •
9. SCREEN: Depth Diameter Slot Size Material
Top 230 Bottom 250 Ft. 4 in. .015 in. PVC
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 220 Bottom 260 Ft. #2
= Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
0 / 10 SAND AND CLAY
10 / 43 CLAY
43 / 58 SAND AND CLAY
58 / 61 ROCK AND SAND
61 / 74 SAND
74 / 110 ROCK AND SAND
110 / 143 SAND (MED)
143 / 144 ROCK 8"
144 / 162 SAND (MED)
162 / 165
165 / 180
12. REMARKS:
ROCK AND SAND
SAND AND CLAY
5.
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT DAN ACCORDANCE WITH
: 15A NCAC 2C, WELL CONSTRUCTION -STANDARDS, AND THAT A COPY OF THIS
: RECO D:HAS BEEN OVID TO 'Ht''(111 "�' 01MVE ��'3ra�. .
▪ t. 11/26/12
OE C
SIGNATURE OF CERTIFIED WELL NTRACTOR
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE
`i 1 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
''";r'5 ----Rev. ___ __�.__..._..-