415224_Well Construction - GW1_20130812

RESIDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environrnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
2942
t. DISINFECTION: Type..,.410 kelt Amount 02 ...
1. WELL CONTRACTOR:
Leonard Dorn, Jr.
Well Contractor (Individual) Name
Well Done Well Drililng
•
Well Contractor Company •Name
STREET ADDRESS P.O. Box 39
Shallotte, NC 28459
City or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable) 2.C& & 0 Si 7 3 0
STATE WELL PERMIT it app cable)
• R ' IT If a oca ie , k 4 / 9 ".DWQorOTHERP��% � �
PP )
WELL USE (Check Appli le Box): Residential Water Supply Er -
DATE DRILLED i
TIME COMPLETED is=r -4 AM O PM
3. WELL LOCATION:
CITY: 63,5 COUNTY Brunswick
/ q red/0- J3 ("1-41,5=-91V:frof
(Street Name. Numbers, Community. Suaoiv sion, Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LAND ETTING:
o Slope_ D Valley lat D Ridge Q Other
(check appropnate box)
LATITUDE 3 �5„ t;/3
LONGITUDE
Latitudellongitude source: @ 'S °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form l not using GPS)
May be in degrees,
minutes. seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME Of 01" /'�C fv142'
STREET ADDRESS 1 -79 C,'— Cd-
CityorTown State • Zip Code
en° }- • iJi
Area code - Phone number
5. WELL DETAILS:1712
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES.( "NO 0
c. WATER LEVEL Below Top of Casing: 447 FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
415224
g. WATER ZONES (depth):
From To From To
From To From To
From To_ From To
6. CASING:
Thickness/
Depth Diameter W eight
From_To 32 Ft. v.,�
FromTo-- Ft.
From ToFt.
7. GROUT: Depth
Material
From 19 To; D Ft. tdI P; )4
FromTo Ft
From To Ft
terial
Method
et 4; It )17
8. SCREEN: Depth , Diam et Slot Size Matenat
From J 2 To .9 7 Ft. if in. e, z. in. 6m3tiL
FromTo Ft.
From To Ft
9. SAND!GRAVEL PACK:
Depth
From To Ft.
From To Ft
From To
10. DRILLING LOG
From To
— _
3
32 ?qua, /
toki
Ft.
in.
un.
in.
S:ze
Ma:ernal
Formation Descrpticn
77i( _50)I
C ,�
y7
11. REMARKS:
ted It I AO
39 al
t l�C 1 ,r ll..t 0,-1 I;;, 11 ,4i
V
•
l 00 HEREBY CERTIFY THAT THIS WELL WAS 'CONSTRUCTED IN ACCORDANCE MTH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TQQTHE WELT OWNER.
7 &V./3
SIGN • TURE OF CERTIFIED • , 4. CONTRACTOR DATE
//Iv Ao
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1 617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05