415223_Well Construction - GW1_20130812

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
City uTown State
910) 754-9311
Area code- Phone number
2. WELL INFORMATION:
Zip Code
SITE WELL ID #(if applicable) 0 Y ;2- ),"
STATE WELL PE MIT#(' applicable
W r TH R EAR if a 4l cable/4't'401)
o,
D Qo 0 � ( PP )
WELL USE (Check Applicable Bo : Residential Water Supply ( '
DATE DRILLED7/)C) / / ,
TIME COMPLETED /2-2" AM 0 PM Er
3. WELL LOCATION:
CITY: (t / V' I/ 51 3'7.00.-
(Street Name. Numbers. Community. Suaaivnsion, Lot No.. Parcet. Coae)
COUNTY Brunswick
TOPOGRAPHIC / LAND SETTING:
Q Slope [Valley t ❑Ridge Q Other
(check appropria.Ie box)
LATITUDE 3 a .5 s tit
_211. 7-c., '567
LONGITUDE
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude so".ce: tGPS p Topographic map
(bcaton of wea must be shown on a USGS topo map and
attached to this form l not using GPS)
4. WELL OWNER �r'�
OWNER'S NAME / `(ltGr�1 'yitt
STREET ADDRESS 9 I J/VC
� A"t- '')?=/
!ter v
City or Town
State .� Zip Code
0 .r 571
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:
Li)
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing:
(Use °+° if Above Top of Casing)
L
NC1de
FT.
d. TOP OF CASING IS FT. Above Land Surface°
`Top of casing terminated attoc below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / (// METHOD OF TEST igle,
415223
f. DISINFECTION: Type 3 t •- 4it( Amount
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
From
From
From
To
To
To
Thickness/
Depth Otamnter We ht Material
To.1 Ft. S �• VO
FromTo� Ft.
From To Ft.
7. GROUT: Depth Material 6:41.Method
Fr P To 2 Ft. CN dUv
FromTo Ft.
From To
Ft.
8. SCREE Depth Diame! r Slot Size Material
From ) To 3-- Ft. / yy in. p 12, m. 7u C....-
From To Ft. in. tn.
Frorn To Ft in. in.
SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
.5-- 7
77
79-
11. REMARKS:
S:ze Ma:ertal
Formation Descr ptcn
eLoy.
5'P
C` t!- Shy%/
PAN*, z It )J
100 HEREBY CERTIFY T1W THIS WEL/ W .S CONSTRUCTED N ACCORDANCE'WrrH
15A NCAC 2C. WELL CONSTRUCTION STvCAROS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROV10ED,THE WELL OWNER.
it)
SIGN PRE OF CERTIFIED ELL CONTRACTOR j DATE
W 0t%Iti17*-1
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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.
Form GW-1a
Rev. 7/05