412215_Well Construction - GW1_20130311

RESIDENTIAL 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 P0. Box 39
Shallotte, NC 28459
City or Town State
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
`G`699/$
STATE WELL PERMIT#(d a licable)
T t�i� bie � ��
DWQ or OTHER P RMI a / 9 { pp )
5- 2
WELL USE (Check Appli Ie B x): Residential Water Supply ii?''a-
DATE DRILLED , ) ) 3
TIME COMPLETED it 30 AM (e/PM 0
3. WELL LOCATION:
CITY: 57 �� COUNTY Brunswick
A
_7
/1-)0air,,, 106,
(Street Name. Numbers, Community, Suovivision, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND ING:
❑ Slope Q Vaitey lat Q Ridge D Other
(check appropriate box)
fi
LATITUDE 3I'
Jel7 wiz
LONGITUDE V it
Latitude/iongitude source: GPS ❑Topographic map
(location 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 rngit 7
May be in degrees,
minutes, seconds or
in a decimal format
7 eyv 4ey
STREET ADDRESS 7'Y9 r
a -//,' /u 617v
City or Town State Zip Code
?
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ya
b. DOES WELL REPLACE EXISTING WELL? YES 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 .0118.
e. YIELD (gpm): METHOD OF TEST
Fr.
412215
R
f. DISINFECTION: Type , r--` r,/. Amount o
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
Dept
From To L
From To
From • To
7. GROUT: Depth
From To
From To
From To
Thickness/
Diameter W eig t terial
Ft. `'y, J G v'
Ft.
Ft.
Material
From 0 To. t, Ft.Cn "V
FromTo FL
From To Ft.
Method
8. SCREEN: Depth Diame�! r Slot Size
From 3`'� To...0_ Ft. / 'in. ig/ 2,--- in.
From To . Ft. in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size P.1a:ertal
Frorn To Ft.
From To F:.
Frorn To Ft.
10. DRILLING LOG
From To
o
L/U
Matenal
Q
Formation Descnptron
I-7 •r`W 0
(L jty
e. V',
Z W 4t ,
VrAingl
AR I 1 2013 , R -4 9°13
WA E QUALITY SECTIQf�
FORMATION P'ROCESSi
�u ......_._..�._ - �-_ .��..d...._. NO UNIT
11. REMA Ks:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. ANO THAT A COPY OF miS
RECORD HAS BEEN PROVIDED TQ''irE WELL • • NER.
SIGNATURE OF CERTIFIED
LL CONTRACTOR DATE
6 Jt ?t
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.
Forrn GW-la
Rev. 7105