410239_Well Construction - GW1_20130114

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 Drillina
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# 910
NC 28557
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) na
SITE WELL ID #(if applicable) na
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 11/7/12
TIME COMPLETED 3:00 AM ❑ PM '.
4. WELL LOCATION:
CITY: Newport couNTY Carteret
101 Pelican Ct
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley EFlat ❑ Ridge ❑Other
LATITUDE 3 - - ° _' 2i379/ " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 7 , yam° ° 57' tictig " 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
Johnny Johnson
Owner Name
101 Pelican Ct
-: 'Av 5 ".11a..
Street Address
Newport NC 28570
City or Town
(252 )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 130
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES Q NO D
c. WATER LEVEL Below Top of Casing: 15 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): 50 METHOD OF TEST a I r
f. DISINFECTION: TypeC lorine Amount .50oz
Top110
g. WATER ZONES (depth):
Top 110 Bottom 130 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 110 Ft. 4 sch40 pvc
Ft.
Ft.
Top Bottom
Top Bottom
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. bentonite
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 110 Bottom 130 Ft4 in.
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Bottom 130
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /35
35
60
90
110
/60
/90
/110
/130
/
/
12. REMARKS:
in. in.
in. in.
Size
Ft.#2
Ft.
Ft.
sand
Method
poured
Slot Size Material
20 in. pvc
Material
sand
Formation Description
sandy clay
clay
fine sandy shell
white rock
f
3Nt'\ 1 y 2i5113
B
soh. 6 253
finformatinn Procabsing unit
1 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.
774'7 1:/>(--,
SIG ° RE OF CERTIFIED WELL CONTRACTOR DATE
D4-9ert )4/10/H-0
//-/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 2/09