382281_Well Construction - GW1_20100408

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# 92
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 03/31/2010
TIME COMPLETED O3/31 /2010 AM ❑ PM ❑
4 WELL LOCATION
ciTY Magnolia COUNTY Dublin
185 Waycross Rd
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ilFlat ❑Ridge
(check appropnate box)
❑Other
LATITUDE 34 ° 51 , 139000
LONGITUDE 78 ° 15 , 22 8000
Latitude/longitude source litPS
(location of well must be shown on a
this form if not using GPS)
5. WELL OWNER
Shelton Batts
Owner Name
185 Waycross Rd
" DMS OR 3x XXXXXXXXX DD
" DMS OR 7x XXXXXXXXX DD
Dropographic map
USGS topo map andattached to
Street Address
Magnolia
City or Town
�)
Area code Phone number
6 WELL DETAILS:
a. TOTAL DEPTH* 207
NC 28453
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO IR(
c WATER LEVEL Below Top of Casing 9 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) 0 METHOD OF TEST Al R
f DISINFECTION• Type HTH Amount 2 Oz
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 192 Ft 2
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Material
Ft hole plug
Ft
Ft
Bottom
Bottom
Bottom
Thickness/
Weight
Material
40 PVC
9 SCREEN Depth Diameter
Top 192 Bottom 207
Top Bottom
Top Bottom
Ft 2 in
Ft
Ft in
10 SAND/GRAVEL PACK
Depth Size
Top 185 Bottom 209 Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /15
15 /22
22 /35
35 /45
45 /50
50 /75
75 / 149
149 /151
151 /178
178 /181
181 /207
207 /209+
12 REMARKS
clay
Method
poured
Slot Size Material
015 in PVC
in
in
' Material
gravel
Formation Descnption
sand and clay
sand
clay
sand
clay
sand and clay
rock 20"
sand with some clay
clay
sand with some clay
clay
90% n r in,
APR 0 8 2010
;.1fcmit'C" Pr-,P5 ¢SIfl3 Unit
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 THE WELL OWNER
I.a(xV i d L tS ^r 04/06/2009
SIGNATURE OF CERT1FJED WELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CO'I Tj.ING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Procestft 0 9 2013
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev 2/09
Form GW-la