387034_Well Construction - GW1_20100908

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
721WEST 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 ❑ Municipal/Public ❑
Industnal/Commercial 0 Agricultural Id Recovery ❑ Injection ❑
Irngation❑ Other 0 (list use)
DATE DRILLED 08/17/2010
4. WELL LOCATION.
1190 LANEFIELD ROAD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WARSAW couNTY DUPLIN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34
° 57 ' 9 7000
"DMS OR 3x xxxxxxxxx DD
LONGITUDE 78 2 9 3000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source 3PS Dropographic 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 )
BI77F1I DAVIS
Facility Name
1190 I ANFFIFI D ROAD
Street Address
WARSAW
Facility ID# (if applicable)
NC
City or Town
B177F1 I DAVIS
State Zip Code
Contact Name
1190 I ANFFIFI D ROAD
Mailing Address
WARSAW NC 28398
City or Town State Zip Code
( 910n 293-4383
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 240
b. DOES WELL REPLACE EXISTING WELL? YES El NO ❑
c WATER LEVEL Below Top of Casing 58 FT
(Use "+" if Above Top of Casing)
Submit within 30 days of completion to: Division of,Water Quality - Information casing, ,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone] ' • t�
1°2014
d TOP OF CASING IS 1.5 FT Above Land Surface'
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) 125 METHOD OF TEST AIR
f DISINFECTION Type HTH Amount 4 07
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth Diameter
Top 0 Bottom 220 Ft 4
Top Bottom Ft
Top Bottom Ft
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
Method
POURED
Slot Size Material
Top 220 Bottom 240 Ft 4 in 015 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 200 Bottom 240 Ft 2 GRAVEL
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 18 SAND AND CLAY
18 / 30 SAND AND SHELLS
30 / 40 CLAY
40 / 75 SAND
75 / 97 CLAY
97 / 103 SAND
103 / 105 ROCK 18"
105 / 165 SAND
165 /190 CLAY
190 / 240 SAND
240 / ROCK
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
REC HAS BEE)! PROVID TO THE^WELL OWNER
cA i1 9/2/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING DAVID L REGISTER rI NED
E
SFFPm0 8 2010
InformAitYnMcessing Unit
DWQ/BOG