411188_Well Construction - GW1_20130204

RESIDENTIAL 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
City or Town
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 218
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
NC 28458
State Zip Code
3. WELL USE (Check Applicable Box): Residential Water Supply Yr
DATE DRILLED 10-16-2012
TIME COMPLETED AM 0 PM 0
4. WELL LOCATION:
CITY: ROSE HILL
HWY 11
COUNTY DUPLIN
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley (if Flat ❑Ridge DOther
LATITUDE 34 48 21.2000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 56 38.2000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: ( PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
JAY LENNON
Owner Name
HWY 11
Street Address
ROSE HILL
City or Town
(910 ) 284-0630
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 200
NC 28458
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ipf
c. WATER LEVEL Below Top of Casing: 1 1 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): 150 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
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g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 185 Ft. 4
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight Material
40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 185 Bottom 200 Ft.4 in.
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
Slot Size Material
.015 in. PVC
in. in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 180 Bottom 203 Ft. #2
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 /20
20 / 50
50 / 72
72 /75
75 /88
88 / 102
102 /130
130 /140
140 /156
156 /158
158 /190
190 /191
191 /200
200 /203
12. REMARKS:
Ft.
Ft.
Material
Formation Description
SAND AND CLAY
SAND (COARSE)
SAND AND CLAY
ROCK AND SAND
SAND (MED)
ROCK AND SAND
SAND (MED)
SAND AND CLAY
SAND (MED)
ROCK 18"
SAND (MED)
ROCK 2"
SAND (MED)
SAND AND CLAY P,
rrir-
E. 2913
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I DO HEREBY CERTIFY THAT THIS WEL 0/AS CONSTRI�CTED1N
ACCORDANCE WITH 15A NCAC 2C, WELIAQNSTRUCTION
STANDARDS, AND THAT A COPY OF THIS�RECORD HAS BEEN
PRO1` /QED TO THE WELL OWNER.
� r e
i/L
. ,. -s�. 1-3-13
• SIGNATURE OF'CERTIFIED WELLCONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF P,ERSON.CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Prod0044, g 2013
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09