411990_Well Construction - GW1_20130304

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2953
1. WELL CONTRACTOR:
Jason P Morton
Well Contractor (Individual) Name
Morton Drilling
Well Contractor Company Name
117 Turners Dairy Rd
Street Address
, Morehead City
City or Town
( 252 ) 222-0513
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#890
OTHER ASSOCIATED PERMIT#(if applicable) na
NC 28557
State Zip Code
SITE WELL ID #(if applicable) n ca
3. WELL USE (Check Applicable Box): Residential Water Supply`(
DATE DRILLED 11/28/12
TIME COMPLETED 3:00 AM ❑ PM LK
4. WELL LOCATION:
CITY: Sealevel
111330 Hwv 70
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAD SETTING: (check appropriate box)
DSlope [Valley Fiat ❑ Ridge D Other
LATITUDE 34 ° dVD (01 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 76 BE ° ' oq " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: PS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Tammy Wood
COUNTY Carteret
Owner Name
PO Box 1524
Street Address
Morehead City
City or Town
(252 ) 269-5515
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:90
NC 28557
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO D
c. WATER LEVEL Below Top of Casing: I 0 FT.
(Use N+" if Above 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): 45 METHOD OF TESTAir
f. DISINFECTION: Type Chlorine Amount .05oz
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411990
g. WATER ZONES (depth):
Top 60 Bottom 80 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom,
7. CASING: Depth Diameter
Top() Bottom 60 Ft.4
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
sch40 pvc
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. bentonite
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 60 Bottom 80
Top Bottom
Top Bottom
Top
Top Bottom.
Top Bottom,
Method
poured
Diameter Slot Size Material
Ft4 in. 20 in. pvc
Ft, in. in.
Ft. in. in.
'10. SAND/GRAVEL PACK:
Depth
60 Bottom 80
11. DRILLING LOG
Top Bottom
0 /35
35 /60
60 /80
/
12. REMARKS:
Size Material
Ft.#2 sand
Ft,
Ft.
Formation Description
sand
sandy clay
rock and shell
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
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S1 TURE OF CBTIFIED%ELL CONTRAC OR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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