385437_Well Construction - GW1_20100712

t,J.e1tD,
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# 4D ia
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 0 Agncultural ( Recovery D Injection ❑
Irngation❑ Other 0 (list use)
DATE DRILLED 05/1 1 /2010
4 WELL LOCATION:
442 Pinev Grove Rd
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
335437
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) 150 METHOD OF TEST AIR
f. DISINFECTION Type HTH Amount 4 oz
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight
Top 0 Bottom 170 Ft 4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 20 Ft hole plug
Material
40 PVC
Top Bottom Ft
Top Bottom Ft
Method
poured
9 SCREEN. Depth Diameter Slot Size
Top 170 Bottom 190 Ft 4 in 015 in
Top Bottom Ft in in
CITY Albertson COUNTY Dublin Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley elat ❑Ridge ❑Other
LATITUDE 35
°6
LONGITUDE 77 ° 47
43 7000
40 7000
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7X XXXXXXXXX DD
Latitude/longitude source IMPS ['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 )
Fmmett Strnund II
Facility Name Facility ID# (if applicable)
442 Pinev Grove Road
Street Address
Alhertsnn NC 28508
City or Town State Zip Code
Fmmett Stroud II
Contact Name
448 Pinev Grove Road
Mailing Address
dAlbertson
City or Town
`b (252,6 560-6256
Area code Phone number
6. WELL DETAILS
a. TOTAL DEPTH 190
b. DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 36
(Use "+" if Above Top of Casing)
NC 28508
State Zip Code
YES ❑ NO gel
FT
Material
PVC
10 SAND/GRAVEL PACK:
Depth Size Material
Top 150 Bottom 190 Ft 2 GRAVEL
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 15 sand
15 / 72 clay
72 / 92 sand and clay
92 / 94 rock 24"
94 / 112 sand medium
112 / 113
113 / 135
135 / 138
138 / 140
140 / 165
165 /190+
12 REMARKS
CIaY
sand
rock 3'
sand
sand
sand
° .v c—"
W�t :�v
•
tin 1 2 Z010
Information i'rvu.,,z, +ifl'3 Unit
DWUi� v
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORDHAS•BEEN PROVIDED TO THE WELL OWNER
•
SIGNATURE OF CERTIFI
06/30/10
WELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE V E
Submit within 30 days of completion to: Division of Water Quality - Information Processing, -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone]
0 C IFor�ntP-1 b
Rev 2/09