385864_Well Construction - GW1_20100714

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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
State Zip Code
910 ) 289-3175
Area code Phone number
2. WELL INFORMATION•
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(if applicable)
d TOP OF CASING IS 1 .5 FT Above Land Surface's''
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) 100 METHOD OF TEST AIR
f. DISINFECTION: Type HTH
Amount
307
• g. WATER ZONES (depth)
NC 28458 Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
3 WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industnal/Commercial ❑ Agncultural ie Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 06/10/10
4 WELL LOCATION'
109 William D. Cavanauah Le
(Street Name, Numbers, Community, Subdivision; Lot No , Parcel, Zip Code)
CITY Wallace COUNTY duDlin
TOPOGRAPHIC / LAND SETTING (check appropnate box)
['Slope ❑Valley WrFlat ❑Ridge ❑Other
LATITUDE 34 " 46 , 12 8000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 77 ° 55 , 38 4000 ^ DMS OR 7x xxxxxxxxx DD
Latitude/longitude source 3PS Qropographic 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 )
Tim West
Facility Name
109 William D
Street Address
Wallace
City or Town
Tim West
Facility ID# Of applicable)
Cavanauah I ane
NC 28466
State Zip Code
Contact Name
109 William D Cavanauah I n
f(uM Mailing Address
Wallace NC 28466
City or Town State Zip Code
( 910n 231-8349
Area code Phone number
6. WELL DETAILS:
a TOTAL DEPTH: 160
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 1 1
(Use "+" if Above Top of Casing)
YES ❑ NOW
FT
• 7 CASING Depth
• Top 0 Bottom 140 Ft 4
Top Bottom Ft
Top Bottom Ft
Diameter Weight
Material
40 PVC
8 GROUT Depth Matenal Method
Top 0 Bottom 20 Ft hole plug poured
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top 140 Bottom 160 Ft 4 in 015 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK:
Depth
Top 135 Bottom
Size Material
160 Ft 2 GRAVEL
Top Bottom Ft
Top
Bottom Ft
11 DRILLING LOG
: Top Bottom
0 /8
Formation Descnption
sand
8 / 20 sand and clay
20 / 40 clay
40 / 84 sand and clay
84 / 86 rock 2'
86 / 100 sand
100 / 113 rock and sand
113 / 119
sand lDICGImo"I E
119 / 120 rock 18" " "" '"
120 / 136 sand fine JUL 1 4 zooe
136/ 138 rock 18"
1214R60 sand
1 rock
Information Pry, Uni4
D4Av0/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
• SIGNATURE OF CERTIFI;D WELL CONTRACTOR DATE
: DAVID L REGISTER
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]
INAS
OCT 2vern -1b