412218_Well Construction - GW1_20130311

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATI
ON # 2942
f. ISINFECTION: T e ' �i�'t .Amount }D `Z.-
D YP
g. WATER ZONES (depth):
1. WELL CONTRACTOR:
Leonard Dorn, Jr.
Well Contractor (Individual) Name
Well Done Well Trilling
Well Contractor Company.Name
STREET ADDRESS P.O. Box 39
Shallotte, NC 28459
City or Torn State
[phone]
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID tt(ii applicable) Q 8 Veo 6,37gi
STATE WELL PERMIT#01 applicabl
DWQ or OTHER PERM{ i ap i le
�/ 2.0#003 9
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED i 'v. ( 3
TIME COMPLETED 0 0 AM ❑ PM 0
3. WELL LOCATION:
CITY: �‘f.) / w� COUNTYBCUIISVVICI{
1-? A62--
(Street Name, Numbers, Community. SuacMsion, Lot No.. Parcel, Zip Cooe)
TOPOGRAPHIC / LA91 SETTING:
❑ Slope (Valley gnat Q Ridge D Other
(check appropriate box)
h '
LATITUDE 3 7p
LONGITUDE 7 ° 2
Latitudellongitude source: E S ❑Topographic map
(bcation of wed must be shown on a USGS topo map and
attached to this form f not using GPS)
4. WELL OWNER
OWNER'S NAME A '� �i " �XS i �``,
0,
STRAT AD RESS 3;P4-0.)Arot
!elk-
ikuf,o
City or Town State Zip Code
1/0
Area code - Phone number •
May be in degrees,
minutes. seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
Pc z $yz2-
b. DOES WELL REPLACE EXISTING WELL? YESErNO ❑
c. WATER LEVEL Below Topof Casing: 9 FT.
(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 .0118.
e. YIELD (gpm): METHOD OF TEST19-7:i1/4.--
From
From
To
To
From To
6. CASING:
41az;8
From To
From To
From To
Thickness!
Depth.7 Diameter Wb/o
jht
From To Ft. $ .5C
FromTo ___ Ft.
From To Ft.
7. GROUT: Depth Material JJ
From /9 To 2 0 Ft. ac,A f T
From To FL
From ToFL
Material
Method
at - if'
8. SCREEN: Depth Diarnete Slot Size Ma anal
From To Yej:.- Ft. % 4n. f O,Z In. ' VL.
From To Ft.
From To Ft in. in.
in. in.
. SAND/GR.AVEL PACK:
Depth
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
3-&
(0.,
;- Z. 2 '3
cr
11. REMARKS:
Sae t.1a:eriai
Formation Descrptlon
ize
c. �--7
5-4-111V)
4oP--7
4-z o-yup
(R 0/4
(LA
MAR 4 2013
,crt�r�".r't+> 77- IN `fi'.l 3fY'" it�.J".". 7,
b ' ION
5+' �kWATER�` UA . Y EC b
INFORMATION PR O SSIWG UNl
Ai1 2013
.�
KS ��7i1
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STAHCARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED,J'O ME WELL OWNER.
r.
lfr
SIGN1'URE OF CERTIFIED W _ •• CONTRACTOR
i)2,&/tj
Z 2--
GATE
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