389582_Well Construction - GW1_20101130

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#
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 10/6/2010
TIME COMPLETED 1 1-05-10 AM ❑ PM ❑
4 WELL LOCATION
CITY Rose Hill COUNTY DuDlin
Hallsville road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley IitFlat ❑Ridge ['Other
LATITUDE 34 ° 53 • 9 8000
LONGITUDE 77
53 . 32 2000
" DMS OR 3x XXXXXXXXX DD
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [PPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
David Wallace
Owner Name
2337 Hallsville Road
Street Address
Rose Hill
City or Town
910 ) 290-0693
Area code Phone number
6. WELL DETAILS
a TOTAL DEPTH: 268
NC 28458
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES I' NO ❑
c WATER LEVEL Below Top of Casing 34 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) 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING: Depth Diameter
Top 0 Bottom 248 Ft 2
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Material
40 PVC
8 GROUT Depth Material
Top 0 Bottom 20 Ft grout
Top Bottom Ft
Top Bottom Ft
9 SCREEN• Depth Diameter
Top 248 Bottom 268 Ft 2
Top Bottom Ft
Top Bottom Ft
10 SAND/GRAVEL PACK
Depth
Top 235 Bottom 270
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /13
13 /40
40 /61
61 / 62
62 /93
93 /133
133 /183
183 /201
201 /235
235 /249
249 /250
250 /269
269 /271+
/
12 REMARKS
in
in
in
Size
Ft 2
sand
Q
Method
poured
Slot Size Material
015 in PVC
in
in
Material
gravel
Formation Descnption
sand and clay
clay
rock 6"
sand
rock hard and sand
clay
rock 4"
clay
sand medium
rock 18"
sand medium
clay r--
NOV 32010
Information ProceS9u 0 Unit
nn�� C)G
1 DO HEREBY CERTIFY THAT THIS WELL" WA$lCONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROuLDED TO THE WELL OWNE
11/23/10
SIGNATURE OF CERTIFIED WELL CQNTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTI9 I 1E WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] OCT 2 4 2013
Form GW-la
Rev 2/09