410238_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 Drilling
Well Contractor Company Name
117 Turners Dairy Rd
Street Address
Morehead City NC 28557
City or Town
( 252) 222-0513
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#678
OTHER ASSOCIATED PERMIT#(if applicable) na
SITE WELL ID #(if applicable) na
State Zip Code
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 7/23/ 12
TIME COMPLETED 4:00 AM 0 PM V
4. WELL LOCATION:
CITY: Newport
510 Blue Heron Bav
COUNTY Cartveret
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope D Valley Li Flat D Ridge ❑Other
LATITUDE 34 El ° 1` 5'10 . " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 76 °r,.' M7 ' , " DMS OR 7X.XXXXXXXXX DD •
Latitude/longitude source: PS DTopographic map
(location of well muss be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Steven Jones
Owner Name
510 Blue Heron Dr
Street Address
Newport NC 28570
City or Town State Zip Code
(252 ) 353-1302
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:140
b. DOES WELL REPLACE EXISTING WELL? YES a NO Lie/
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): 55 METHOD OF TEST a I r
f. DISINFECTION: TypeClllOt'Itl@ Amount .50OZ
•
g. WATER ZONES (depth):
Top 120 Bottom 140
Top Bottom
Top Bottom
7. CASING: Depth
Top 1 Bottom 120
Top
Top
Bottom
Bottom
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
410 f
Top Bottom
Top Bottom
Top • Bottom
Thickness/
Diameter Weight Material
Ft.4 sch40 pvc
Ft.
Ft.
Material Method
Ft. bentonite poured
Ft.
Ft.
9. SCREEN: Depth Diameter Slot Size
Top 120 Bottom 140 Ft4 in. #20in.
Top, Bottom Ft in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 120 Bottom 140 Ft.#2
Top Bottom
Top Bottom_„�___�,,,,
11. DRILLING LOG
Top Bottom
0 . /35
35 /80
80 /120
120 /140
12. REMARKS:
Ft.
Ft.
sand
Material
pvc
Material
sand
Formation Description
sandy clay
clay
white rock
RECEIVcD
JAN 6 2-02
Information Processing Linil
DW /BOG
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.
ram' T G'"'
SIGN ORE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
orra"
focesisln. h
Form GW-la
Rev. 2/09