389086_Well Construction - GW1_20101112

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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#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industnal/Commercial 0 Agncultural ( Recovery ❑ Injection ❑
Irngation❑ Other 0 (list use)
DATE DRILLED 10/18/10
4 WELL LOCATION.
3465 HWY 111 & 903
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY ALBERTSON COUNTY DUPLIN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 35 0 9 44 4000 "DMS OR 3x xxxxxxxxx DD
LONGITUDE 77 ° 48 29 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source l4PS [Topographic 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 )
BFNJAMIN DAVIS
Facility Name
3465 HWY 111 & 903
Street Address
Al BFRTSON
City or Town
BFNJAMIN DAVIS
Contact Name
3465 HWY 111 & 903
Mailing Address
Al BFRTSON
City or Town
( 252o 559-0422
Area code Phone number
6 WELL DETAILS:
a. TOTAL DEPTH: 170
Facility ID# (if applicable)
NC 28508
State Zip Code
NC: 28506
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lyr
c. WATER LEVEL Below Top of Casing 49
(Use "+" if Above Top of Casing)
FT
3 g 9 0 8
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
•
9
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 150 Ft 4 40 PVC
WATER ZONES (depth)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9 SCREEN Depth
Top 150 Bottom 170
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 145 Bottom 175
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
0 / 40
40 / 75
75 / 80
80 / 105
105 /115_
115 / 116
116 / 122
122 / 138
138 / 172
172 / 180+
12 REMARKS:
Matenal Method
Ft HOLE PLUG POURED
Ft
Ft
Diameter Slot Size Material
Ft 4 in 015 in PVC
Ft in in
Ft in in
Size
Ft 2
Ft
Ft
Material
GRAVEL
Formation Descnption
SAND
SAND AND CLAY
SAND
CLAY
SAND
ROCK 2"
SAND
ROCK AND SAND
SAND r-Iok icrt
MaAY> 8vL.e
NUV1h .u'
Intormatiui i i 0'.
Ilna
vC. 1Ain/WI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT!QN STANDARDS, AND THAT A COPY OF THIS
RECO 3 HAS BEE p1IPROVjDED Tpj/rHE-WELL OWNER
11/08/10
SIGNATURE OF CERTIFIED ELL CO• NTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit withim30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone]
Form GW-lb
O C 12 4Re J09