386652_Well Construction - GW1_20100827

LONGITUDE 77 0 45 • 00000 " DMS OR 7x xxxxxxxxx
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
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#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industnal/Commercial 0 Agricultural iifr Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 07/12/2010
4 WELL LOCATION
605 CYPRESS CREEK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 46 52 5000 •• DMS OR 3x XXXXXXXXX DD
DD
Latitude/longitude source WPS ['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 )
TIM MARFADY
Facility Name Facility ID# (if applicable)
605 CYPRFSS CRFFK ROAD
Street Address
WAI I ACE NC
City or Town State
TIM MARFADY
Contact Name
605 CYPRFSS CRFFK ROAD
Mailing Address
WAI I ACE
City or Town
+j ( 910n 289-1168
Area code Phone number
'Jo 6. WELL DETAILS:
V
a TOTAL DEPTH• 239
b. DOES WELL REPLACE EXISTING WELL?
NC
State
28466
Zip Code
28466
Zip Code
YES NO Gil
c. WATER LEVEL Below Top of Casing 25 FT
(Use "+" if Above Top of Casing)
3
F2
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) 45 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 184 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
•
9. SCREEN Depth Diameter
Top 184 Bottom 239 Ft 4 in
Top Bottom Ft in
Top Bottom Ft in
•
10. SAND/GRAVEL PACK
Depth
Top 170 Bottom 255
Size
Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /3
3 / 15
15 / 50
50 / 135
135 / 150
150 / 180
180 / 186
186 / 233
233 / 243
243 / 255
12. REMARKS -
Method
POURED
Slot Size Material
015 in PVC
In
in
Material
GRAVEL
Formation Descnption
SAND
SAND AND CLAY
CLAY & THIN ROCKS
CLAY
SAND
SAND & CLAY
SAND
ROCK
SAND AND CLAY
AUG 2 7 2010
In
I DO HEREBY CERTIFY THAT THIS WELL WAS C =T�r� PC E AtieChlatNCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDAR COPY OF THIS
R ORD HAS BEEN PROVIDE 0 THE WELL OWNER
CUAtiCt 8/3/10
SIGNATURE OF CERTIFIED ELL 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]
,F,grm GW-lb
q Rev /09
FEB 1 201