410444_Well Construction - GW1_20131231

RESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of \Vatcr 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 P.O. Box 39
Shallotte, NC 28459
Cilva Town State
[phone]
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) of D 7 / 1,2
STATE WELL PERMIT#0 applicable)
DWQ or OTHER PiR a
WELL USE (Check Applicabt - Box): Residential Water Supply (E
DATE DRILLED 2,
ftgaVe) Aqipetz 9
TIME COMPLETED * ° ` AM O PM
3. WELL LOCATION:
CITY: D COUNTY Brunswick
"7 itew474/1) let/47
(Street Name. Numbers. Community. Suaonnsion. Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3 / o .., 3 2''
LONGITUDE -2 4.- J, 7
May be in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: 0 GPS oTopographic map
(location of we, must be shown on a USGS topo map and
attached to this form r not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADORES
Air E.. 7 6y z 0
City or own State
e-/20
14,497
' y Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
5-72 c 7 fueimennu, 14-0,
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES' NO 0
c. WATER LEVEL Below Top of Casing: FT.
(Use if Abov. 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): / 5— METHOD OF TEST ,4
f. DISINFECTION: Typ
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
Depth
From To 40
FromTo
From To
7. GROUT: Depth
sn 4
Amount _it "2.-
From To
From To
From To
Thickness!
Diameter . W eig t Mated
Ft.5 C 11, St'
Ft.
Ft.
Material
From 6 , To i I) Ft. 736, '
From To Ft.
From To Ft.
Method
CP t"147
8. SCREEN• Depth Dump, Slot Size MqLenal
From y0 To 5131 Ft. in. -,+n. yy
FromTo Ft.
in.
From_______ To Ft ___in. in.
9. SAND/GRAVEL PACK:
Depth
From To
Frorn To
From To
10. DRILLING LOG
From To
YZ-
11. REMARKS:
Ft.
Ft.
Ft.
Sze Ma:ertal
Formation Descr pticn
tL )9 7
5-$141)
I> 1g k
.`" 2012
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED WI ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION ST).HC1,ROS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO 't]r�'t(ELL OWNER.
SIG URE OF CERTIFIED WELL NTRACTO._
tit) Gat
PRINTED NAME OF PERSON CONSTRUCT1V
do
TAJAT
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.
G -la
Rev. 7/05