382537_Well Construction - GW1_20100416

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# 23427
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 ❑ Agncultural ❑ Recovery ❑ Injection ❑
Irrigationl" Other ❑ (list use)
DATE DRILLED 06/09/2010
4 WELL LOCATION
844 JAMES ROAD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
clTY WALLACE
TOPOGRAPHIC / LAND SETTING
DSlope ❑Valley V(Flat ❑Ridge
LATITUDE 34
LONGITUDE 77
" 44 ' 693 0000
" 43 809 0000
COUNTY DUPLIN
(checx appropriate box)
❑ Other
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source VGPS Oropographic 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 )
ROBFRT SHOLARL,
Facility Name
844 JAMES ROAD
Street Address
WAI I ACE
City or Town
ROBFRT SHOI AR
Contact Name
844 JAMFS ROAD
Facility ID# (if applicable)
NC 28466
State Zip Code
Mailing Address
WAI I ACE
City or Town
�)
Area code Phone number
M6. WELL DETAILS
a TOTAL DEPTH 250
r`�O
d
NC 28466
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑
NOq/
c WATER LEVEL Below Top of Casing 30 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 vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) 60 METHOD OF TEST AIR
f DISINFECTION Type HTH Amount 10 pellets
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 220 Ft 4 015 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 5
Top 5 Bottom 20
Top Bottom
Material
Ft CEMENT
Method
PUMPED
Ft HOLE PLUG POURED
Ft
9 SCREEN• Depth Diameter
Top 220 Bottom 250 Ft 4 in
Top Bottom Ft in
Top Bottom Ft in
. 10. SAND/GRAVEL PACK.
Depth Size
Top 230 Bottom 260 Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 20
20 / 24
24 / 25
25 / 30
30 / 35
35 / 65
65 / 85
85 / 118
Slot Size Material
015 in PVC
In
Material
GRAVEL
Formation Descnption
SAND
SAND AND CLAY
HARD ROCK 16i
ROCK AND MARL
SAND AND CLAY
ROCK AND CLAY
SAND. CLAY. AND ROCK
SAND AND CLAY
118 / 138 SAND
138 / 150
150 / 157
12 REMARKS
CLAY
SAND
F�a fra- r, a 6 r
IW Li x
APR 16 2010
i iii ,i u9i ' i.,<�-3in Unit
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE/WW(TH-
EN ROVIDED T THE WELL OWNER
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY dF' iuiIS
RECO HAS E
SIGNATURE OF CERTIFIED
DAVID L REGISTER
tAA.44 06/15/(19
LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
TMS
Submit within 30 days of completion to: Division of Water Quality - Information Processins,EC 0 9 2013
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-lb
Rev 2/09