385863_Well Construction - GW1_20100714

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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#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) -
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ( Recovery ❑ Injection 0
Irrigation@f Other ❑ (list use)
DATE DRILLED 06/09/10
4 WELL LOCATION
RED FOX RUN
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WALLACE COUNTY DUPLIN
NC 28458
State Zip Code
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope [Valley elat ❑Ridge ❑Other
LATITUDE 34 ° 45 ' 21 9000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 77 0 55 ' 48 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 )
nAVin FUSSFI I ,IR Facility Name Facility lD#(ifapplicable)
RFD FOX RUN (RIVFRI ANDINGI
Street Address
WAI I ACF
City or Town
nAVIn FIISSFI I ,1R
Contact Name
PO RnX 756
NC 78466
State Zip Code
Mailing Address
ROSF HII 1 NC 28-
City or Town State Zip Code
( 910. 285-6698
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH 177
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cry
c. WATER LEVEL Below Top of Casing 24
(Use "+" if Above Top of Casing)
FT
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) 150 METHOD OF TEST AIR
f DISINFECTION Type HTH Amount 4 07
g WATER ZONES (depth)
. Top
. Top
Top
Thickness/
7. CASING Depth Diameter Weight Material
Top 0 Bottom 162 Ft 4 40 PVC
: Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
• Top 0 Bottom 20 Ft HOLE PLUG POURED
Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
. Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 162 Bottom 177 Ft 4 in 015 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top 150 Bottom 178 Ft 2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
108 / 115
Size
Material
GRAVEL
Formation Description
SAN D
115 / 116 ROCK 6"
116 /120 CLAY
120 / 128 SAND
128 / 130 ROCK 18"
130 / 177 SAND
177 / 178+ SAND AND CLAY
• 12 REMARKS
RECEIVED
JUL 1 4 2010
info i n:3ticn r''9Cessin0 unit
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INjR{iFMTH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY Op THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- SIGNATURE OF CERTIF ED WELL CONTRACTOR DATE
• DAVID L REGISTER
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality - Information Processing,��
CCT 2 .. 2013
r c nr
1617 Mail Service Center, Raleigh, NC-27699-161, Phone ` (919) 9C, ) o� •a - 30C
Form GW-lb
Rev 2/09