382536_Well Construction - GW1_20100416

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# 89
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 04/08/2010
TIME COMPLETED 04/08/2010 AM ❑ PM ❑
4 WELL LOCATION
CITY KENANSVILLE COUNTY DUPLIN
915 SUMMERLINS CROSSROADS
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
El Slope ❑Valley
LATITUDE 35
LONGITUDE 77
I 'Flat ❑ Ridge ❑ Other
0 ' 41 3000 " DMS OR 3x XXXXXXXXX DD
20 , 21 6000 " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source ItPS ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
PETRA GARCIA
Owner Name
915 SUMMERLINS CROSSROADS
Street Address
KENANSVILLE NC 28349
City or Town State Zip Code
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Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH• 152
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ig
c WATER LEVEL Below Top of Casing 42 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) 20 METHOD OF TEST AIR
f DISINFECTION. Type HTH Amount 20Z
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING Depth Diameter
Top 0 Bottom 142 Ft 2
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
Top 142 Bottom 152
Top Bottom
Top Bottom
Method
POURED
Diameter Slot Size Material
Ft 2 in 015 in PVC
Ft in in
Ft in in
10. SAND/GRAVEL PACK.
Depth
Top 132 Bottom 155
Size Material
Ft 2 GRAVEL
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /20
20 /56
56 /65
65 /82
82 /88
88 /92
92 /102
102 /104
104 /109
109 /120
120 /128
128 /140
140 /152
152 /155+
12 REMARKS
Formation Descnption
SAND
CLAY
ROCK AND CLAY
ROCK AND SAND
SAND AND CLAY
ROCK AND SAND
SAND AND CLAY
ROCK 18"
SAND
CLAY
ROCK AND SAND
SAND AND CLAY
SAND
SAND AEI-CLAY-7n Fr"
APR 1 2nln
Information Pioc€ssonq 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
PRO\(IDED TO THE WELL OWNER
SIGNATURE OF CERTIFIE
04/12/2010
ELL CONTRACTOR DATE
Submit within 30 days of completion to: Division of Water Quality - Information Processing,-
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCT G THE WELL
DEC 092013
Form GW-la
Rev 2/09