385862_Well Construction - GW1_20100714

ON ` E ESIDENTL4L 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#Of applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industnal/Commercial 0 Agricultural Id Recovery ❑ Injection ❑
Irngationli Other 0 (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)
DSlope ❑Valley kiFlat ❑Ridge ❑Other
LATITUDE 34 ° 45 . 21 9000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 77 ° 55 . 48 3000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [PPS Dtopographic 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 )
DAVID FUSSFI L. JR
Facility Name Facility ID# (if applicable)
RFD FOX RUN (RIVFRI ANDINGI •
Street Address
,, WAI I ACE NC 28466
r1J City or Town State Zip Code
DAVIT FUSSFI I . JR
Contact Name
PO ROX 756
Mailing Address
ROSE HII L
City or Town
( 91018 285-6698
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH. 177
NO 28458
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO Cif
c. WATER LEVEL Below Top of Casing 24 FT
(Use "+" if Above Top of Casing)
d
e
f.
TOP OF CASING IS 1 .5 FT Above Land 5urfact * 4 0
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
YIELD (gpm) 150 METHOD OF TEST Al R
DISINFECTION Type HTH Amount 4 07
• 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 162 Ft 4 40 PVC
Top Bottom Ft
Top Bottom Ft
_ 8 GROUT Depth Material Method
Top 0 Bottom 20 Ft HOLE PLUG POURED
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 Size
. Top 150 Bottom 178 Ft 2
Top Bottom Ft
• Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 12
Material
GRAVEL
Formation Descnption
SAND
12 / 50 SAND AND CLAY
50 / 75 CLAY
75 / 82 SAND
82 / 83 ROCK 8"
83 / 87 SAND
87 / 88 ROCK 12"
88 / 97 SAND
97 / 100 CLAY
100 / 101
101 / 104
12 REMARKS
ROCK 12' ^.
SAND RhCE VF n
J�II 4 2010
I DO HEREBY CERTIFY THAT THIS WELL WAS CONdfitMOMFMCWAlogrOnit
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT 430(9
- RECORD HAS BEEN PROVIDED TO THE WELL OWNER
: a WL-& 4 , cAt, � 06/10/10
. SIGNATURE OF CERTIFIED W LL CONTRACTOR DATE
DAVID L RFGISTFR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh; NC 27699-161, Phone [phone]
‘t$ c Form GW-1 b
QCT 2 4 7 j 2/09