383470_Well Construction - GW1_20100513

NON 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# 23581
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑
Irrigation(i Other 0 (list use)
DATE DRILLED 04/12/10
4 WELL LOCATION.
RED BERRY ROAD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WALLACE COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley EtFlat ❑Ridge ❑Other
LATITUDE 34 ° 44 50 7000 " DMS OR 3x XXXXXXXXX
LONGITUDE 77 ° 55 126000 " DMS OR 7x XXXXXXXXX
Latitude/longitude source VGPS OTopographic 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 )
JOHN TAl ATINIAN
Facility Name
RED RFRRY
DD
DD
Facility ID# (if applicable)
Street Address
WAI 1 ACE
City or Town State Zip Code
JOHN TAI ATINIAN
Contact Name
RED-RFRRY
,-/ Mailing Address
JJ WAl LACE NC 2i'i466
U\ City or Town State Zip Code
( 910, 284-5111
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 150
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO C>�
c WATER LEVEL Below Top of Casing 5 FT
(Use "+" if Above Top of Casing)
3
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) METHOD OF TEST AIR
. f DISINFECTION Type HTH Amount
: 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 140 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 140 Bottom
Top Bottom
Top Bottom
Method
POURED
Slot Size Material
150 Ft 4 In 015 in PVC
10 SAND/GRAVEL PACK
Depth
Top 135 Bottom
Top
Top
Bottom
Bottom
11 DRILLING LOG
• Top Bottom
•
0
15
16
30
55
65
74
91
96
112
117
/ 15
/ 16
/ 30
/ 55
/ 65
/ 74
/91
/ 96
/ 112
/ 117
/ 122
Ft in in
Ft in in
Size Material
150 Ft 2 GRAVEL
Ft
12 REMARKS
Ft
Formation Descnption
SAND
0
HARD PAN 3"
CLAY
SAND AND CLAY
CLAY
SAND
ROCK AND SAND
CLAY
ROCK AND SAND( —
CLAY`H
SAND w 1 '1 701U
lVt►-', i
tntOr,�i� •nWCI��{�L
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO E WELL.OWNER
- a� N 05/10/10
SIGNATURE OF CERTIFIED LL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality ; Information Plods
S
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone], ' -DEC ® 9 2013
Form GW-lb
Rev 2/09
D