415227_Well Construction - GW1_20130812

RESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2942
1. WELL CONTRACTOR:
Leopard Dorn, Jr.
Well Contractor (Individual) Name
Well Done Well Drilling
Well Contractor Company.Name
STREET ADDRESS P.O. Box 39
Shallotte, NC 28459
City aTown State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) +� (*t 7
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
l'13
DATE DRILLED
J:'O%)
TOP GRAPHIC/LAND SETTING:
lope ❑Valley ❑ Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 „� V5", &)Y
LONGITUDE i v� 2-0 source: oGPS ❑Topographic map
(:cation of we, must be shown on a USGS topo map and
attached to this form f not using GPS) d3j g k ffr,
4. WELL OWNER 4.1
OWNER'S NAME 1116171 1,2"Vt.) idtc'T,5
STREET ADDRESS '5; '' Jr' Ab P$t-
AM O PM-'
TIME COMPLETED
3. WELL LOCATION:
CITY: 5'� er M COUNTY B runswic
;6 11- -5445;eQy L.tow Aq 00
..•
(Street Name. Numbers. Community. Suaoiws:on, Lot No.. Panel. Zip Coa
it.„
f�4
May Ix in degrees,
minutes, seconds or
in a decimal format
''ItP)hG4://- PC g-96/
City or Town State Zip Code
7/4 z y- o 9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
72,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q
c. WATER LEVEL Below Top of Casing: CI)FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / 0 METHOD OF TEST 7-
5 22 7
f. DISINFECTION: Type /9 %/, Amount JO
g. WATER ZONES (depth):
From To From To
From To From To
To From To
From
6. CASING:
Thickness)
Depth Diameter Weight M eal�
From To_
m Ft., , �'i 9.4 Cr
From______ To Ft.
From To Ft.
7. GROUT: Depth Material y Method
From C9 To 0 Ft. 674.1 &Pi Olt- 1-0- ‘017
From To FL
From To Ft.
8. SCREEN: Depth Diamer Slot Sue Mgkenal
From To Ft. j)/%fin. ' : 'V
Frorn To Ft. in. in.
From To Ft in. in.
SAND/GRAVEL PACK:
Depth S:2e t.la:er3ai
From To Ft.
Frorn To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Descrpt,cn
— YIND
11. REMARKS:
S �'I �y-12
-
tc
1
013
C
00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N-ACC0ROAfCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED SO THE WELL 0 ER.
4'3
CONTRACTOR DATE
a u.de
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-la
Rev. 7/05