414028_Well Construction - GW1_20130610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qu.ality
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 or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
0,5-0/0%96
STATE WELL PERMITAV a splicable)
,„„, , „
DWQ or OTHER PERMIT anifitaiej /VVV/
WELL USE (Check Applicable Box): Residential Water Supply (31
DATE DRILLED
TIME COMPLETED /2/' AM 0 PM
3.WELL LOCATION:
voi3//it
al: ail t. 42-1: v
CITY:
COUNTY Brunswick
treet Name. Numbers. Community. Suoolvisson. Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
Slope [Walley figat 0 Ridge 0 Other
(check appropriate box)
OP
LATITUDE 3 CYr41ZItY
LONGITUDE 7_5K ey, 7/ 4.
Latitude/longitude source: LAPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Inot using GPS)
/ 401
4. WELL OWNER iN
OWNER'S NAME ty.kmell 414 ru 63e
May be in degrees.
minutes. seconds or
in a decimal forrnat
STREET jkDDRESS 61 0 ''' 1, z-4
.7-1144 fuc .2. I q 10 2-
City or Town State Z p Code
(0/ & ''. 3 461)
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESfJ NO 0
c. WATER LEVEL Below Top of Casing:
(Use '+' if Abova 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 .011a.
e. YIELD (gpm): - 19--
METHOD OF TEST
FT.
Depth
From IV To
From To
From To
Ait07,8
,„,
f. DISINFECTION: Type 57,Zet L Amount
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
From To
From To
From To
•
Thickness/
Diamper Weiot Material
Ft. .1, ctA ?a
dVV—
Ft.
. Ft. •
7. GROUT: Depth Material
From 0 To 1 ° Ft. et„dop.
From, To
From To
8. SCREEN:
From...4
From
From
FL
FI
Meth
2d
if di
r Slot Size Material
n. a 0 /2---in. 8to° L.Depth ____. D,
Toc3 Ft.
To Ft. in. in.
To Ft in. in.
. SAND/GRAVEL PACK:
Depth S:ze Ma:erial
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
ki7
11. REMARKS:
F rmation Descnptcn
Vp.4.9
t 111-
141 16t6.4
ti.07
ft, ie. k
"9 v47
t
to' JUN IN 1-41.4Au
INFOR MATI N PR
3
EC:Tic*
SSING UNIT
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrni
15A NCAC 2C. WELL CONSTRU TION STANCAROS. AND THAT A COPY OF THIS
RECORD HAS SEEN PROVIDE, 0 'THE W ' OWNER.
SIGNA
RE OF CER FIE sirELL CONTRACTOR
2.ICJ A atiiJ Te•
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center Raleigh, NC 27699-1617 • Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05