412216_Well Construction - GW1_20130311

RESIDENTJA L 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
Citv or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
S 1TE WELL ID #(if applicable)
-5v7 124 V
STATE WELL PERMIT#ot applicable)
DWQ or OTHER1 Rt if a lica�l� // 3 0000 6
Q E ( pp
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
�fiLll/3
TIME COMPLETED ! ' 0 AM 0 PM E2r
3. WELL LOCATION:
CITY: ttirNAli- (54 V✓ COUNTY Brunswick
ti LP eL sa 4' 2'
(Street Name. Numbers. Community. Suaoiwsion. Lot No.. Parcel, Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
Q Slope °Valley 1t 0 Ridge ° Other
(check appropriate box)
LATITUDE 3 it: , 5')„ H I(
LONGITUDE �. 1 ► ,. +� �
Latitude/longitude source: p.S °Topographic map
(location of wen must be shown on a USGS topo map and
attached to this form f not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
cscIi' c/L,1
STREET ADDRESS%16V . 6) iiA-2' AIL
v► 0,a-a0 pJ C %Z' Z7
City or Town State Zip Code rr
( /1; )- 51- Yis-, /7 K 7
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
H
b. DOES WELL REPLACE EXISTING WELL? ' YES 0
c. WATER LEVEL Below Top of Casing:
C
NO 21
FT.
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS 1 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): /5/ METHOD OF TEST /9'
r;/
412216
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From To
From To
teL
r,Amount
6. CASING:
Depth
From i To 3
From To
From To
7. GROUT: Depth
FromTo
From To
From To
Ft.
Ft.
Ft.
Ft.
Ft.
Ft.
From To
From To
From To
Thickness/
Diamter Weight Mt�
2,L.V c
Materi
Method
8. SCREEN: Depth Dame..!Fr _ Slot Size Matenal
From 31 VS-7
To, Ft. 1 ,din. 40 / 2. in. Pi/ (-
From To Ft. in. in.
i
From To Ft in. in.
. SAND/GRAVEL PACK:
Depth
From
From
From
To
To Ft.
To Ft.
10. DRILLING LOG
From To
0 — 3
3-- L
3 "` y5-_
V ?
11. REMARKS:
Sze
F t. -'
Material
Formation Description
Tor 3,o.
c
Cvp
19 J *#4.0 "oiLl
C ( %
Ld41
R -4 2013
WATER QUALITY SFCTIO
INFORM, IO FROOE SiNGtINFr
AR 1 2W3
BY:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION ST+CAROS. AND THAT A COPY OF THIS
RECORD HAS BEEN. PROVIDED TO TH ' ELL OW R ELL R.
-211 1/4/k
SIGNATURE OF CERTIFIED Yam' CONTRACTOR DATE
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