411085_Well Construction - GW1_20130204

1. WELL CONTRACTOR:
Jason P Morton
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2953
Well Contractor (Individual) Name
Morton Drillina
Well Contractor Company Name
117 Turners Dairy Rd
Street Address
Moerhead City
City or Town
( 252 ) 727-1684
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 915
OTHER ASSOCIATED PERMIT#(if applicable) na
SITE WELL ID #(if applicable) na
NC 28557
State Zip Code
3. WELL USE (Check Applicable Box): Residential Water Supply D
DATE DRILLED 1 /10/1.3
TIME COMPLETED 4:00 AM D PM D
4. WELL LOCATION:
CITY: Morehead City
4103 Plantation Rd
COUNTY Carteret
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑Valley D Flat DRidge ❑Other
LATITUDE 34 ' 0 "DMS OR 3x.xxxxxxxxx DD
LONGITUDE 76 0 ° `ot as. "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
Melissa Georae
Owner Name
4103 Plantation Rd
Street Address
Morehead City
City or Town
(252 ) 727-1684
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
NC 28557
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO D
c. WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" 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): 40 METHOD OF TESTAIr
f. DISINFECTION: Type Chlorine Amount .05oz
Top 060
g. WATER ZONES (depth):
Top 70 Bottom 80
411085
Top 160 Bottom 180
Top - Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 1 Bottom 160 Ft.4 sch40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 20
Material
Ft bentonite
Top Bottom Ft.
Top Bottom Ft.
Method
poured
9. SCREEN: Depth Diameter Slot Size Material
Top 160 Bottom 180 Ft4 in. 20 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Bottom 180 Ft.#2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /35
35 /70
70 /80
80 /160
160 /180
12. REMARKS:
sand
Material
sand
Formation Description
sandy clay
shell sand
grey clay
rock
r'r
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.
E� g' era f p it
/SIG TURF OF CE TIFIED WELL ONTRACTOR DATE
g1/4 filii-OrL±C14/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
.SLibm4 within 30 days of completion: to.:. Division of Water Quality Information Processi �1a r1.617 Mail Service Center, Raleigh, NC 27699-161., •Phone : [phone] Rev. 2/09
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