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HomeMy WebLinkAbout385862_Well Construction - GW1_20100714ON ` 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 (919) 807-6300 ‘t$ c Form GW-1 b QCT 2 4 7 j 2/09