381672_Well Construction - GW1_20100316

NONRESIDENTIAL 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
c1 ( '(l
d J�
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
Street Address g. WATER ZONES (depth)
ROSE HILL NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT# 23833
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Of applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industnal/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
IrrigationGl Other ❑ (list use)
DATE DRILLED 03/01/2010
4 WELL LOCATION
Hamilton Road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Magnolia COUNTY Dublin
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley 11Flat ❑Ridge ❑Other
LATITUDE 34 ° 54 3 9000 "DMS OR 3x xxxxxxxxx DD
LONGITUDE 77 ° 59 28 8000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source IMPS ❑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 )
David Chestnutt
Facility Name Facility ID# (if applicable)
Hamilton Road
Street Address
Maannlia NC 28453
City or Town State Zip Code
David Chesnutt
Contact Name
458 Hamilton Road
Mailing Address
Magnolia NC 28453
Uo City or Town State Zip Code
11 (910, 296-7357
Area code Phone number
6 WELL DETAILS.
a. TOTAL DEPTH: 215
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO r/
c. WATER LEVEL Below Top of Casing 31 FT
(Use "+" if Above Top of Casing)
Amount
3 07
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom 190
Top Bottom
Top Bottom
8 GROUT Depth
Top 0 Bottom 20
Thickness/
Diameter Weight
Ft 4
Ft
Ft
Material
Ft Hole Plug
Material
AD_ PVC
Top Bottom Ft
Top Bottom Ft
Method
Poured
9 SCREEN Depth Diameter Slot Size
Top 190 Bottom 215 Ft 4 in 015 in
Top Bottom Ft in in
Top Bottom Ft in in
Material
PVC
10 SAND/GRAVEL PACK:
Depth Size
Top 180 Bottom 217 Ft #2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /8
3_/ 17
17 / 80
80 / 87
87 / 103
103 / 110
110 / 117
117 / 140
140 / 142
142 / 143
143 / 145
12. REMARKS:
Material
GRAVEL
Formation Descnption
SAND
CLAY
SAND AND CLAY
CLAY
SAND
CLAY
SAND AND CLAY
SAND
CLAY
ROCK-12' i,- F r
CLAYS v
KIr%R 1 6 2010
P IPi JP Pf Pllft ,r•S n� P,ti'u
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A AC 2C, WELL CONSTRUCTION STANDARDS AND THATTA COPY OF THIS
RE HASBEEPRO}FIDED TO,IIE WELL OWNER y1
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]
\
FEB 1 7 2CV
Form GW-lb
Rev 2/09