410443_Well Construction - GW1_20131231

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
2942
1. WELL CONTRACTOR:
Leonard Dorn, Jr.
Well Contractor (Individual) Name
Well Done Well Drilling
Well Contractor Company•Name
STREET ADDRESS P.O. Box 39
Shallotte, NC 28459
Cava Tarn State
[phone]
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) C0. 6 g Ira -
STATE
WELL PERMIT#0 app icable)
DWQE4Falgbi) / 3 V 0 9 7 i or 0THER PR #
WELL USE (Check Appiicab Box): ' esidentiat Water Supply [�'
DATE DRILLED /0 t (2'
TIME COMPLETED 0 AM 0 PM Er-
1. WELL LOCATION:
CITY: 54'? / % COUNTYBrUIISWiCk
ei) Q P/Mta?I
-
(Street Name. Numbers. Community. Suaoly s3on. Lot No.. Parcel, Zip Coae)
TOPOGRAPHIC / LAND ETTING:
❑ Slope O Valley g..crat D Ridge D Other
(check appropnate box) LATITUDE 3 poi / (�
2
LONGITUDE _21
7, Y76
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: °GPS °Topographic map
(bcation of we# must be shown on a USGS topo map and
tcvzleti a5
attached to this form T not using GPS) >�
4. WELL OWNER
7-r OWNER'S NAME • elh
STREET ADDRESS 7--I ti
(3440 ' c z tit/
City or Town State Zip Code
0 7 7/
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO.Er
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST i9
.�. n1: 3
w
f. DISINFECTION: Type <1",r-fleft t Amount
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
From 0
From
Frorn
Depth Dram;ter
To3 ,Ft.
ToFt.
To Ft.
To
To
To
Thickness/
Weight
J)/di
Mater_ial
7. GROUT: Depth Material Method
From n To Ft. 6 zit ciON ,� i-e
FromTo Ft.
From To FL
8. SCREEN:, Depth Diam�e' r Slot Size Matenal
From, ) To7,Ft/ t% in. ; i / 'Zin. L/ (--
From To Ft. in. un.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Sae Material
From To Ft.
From To Ft.
Frorn To Ft.
10. DRILLING LOG
From To
0 -
-
-6
3 6 -
11. REMARKS:
Formation Descnptcn
4zy
V--14'S
he) 4- <1,-Avu,
00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WrTH
15A NCAC 2C. WELL CONSTRUCTION STA iCAROS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO Th ►ELL OWNER.,
r.
SIGNATURE OF CEI5 IED W
A . Lu .
oa
ONTR4NOTOR
A
rr
PRINTED NAME OF PERSON CONS
UCTIHG T}- E
Lui 1 2013
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt_,
1617 Mail Service Center- Raleigh, NC 27699-1617 • Phone No. [phone] ext 568.
GW a
Rev. 7/05