410147_Well Construction - GW1_20130211

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION # 2942 A
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
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(910crtr) 754-9311
State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) JO/ 2, 0 7 / 2, 2. 3
STATE WELL PERMIT#{if applicable)
W OTHER PERMIT # i a ilea le
DWQ o0 E { PP ) 40,, 3')
000 z 5"0 5
WELL USE (Check Applicabl I"Box): esidential Water Supply 0
DATE DRILLED j //9/i
2-'
TIME COMPLETED / 2./ {
+ 0 AM 0 PM
3. WELL LOCATION:
CITY: r P COUNTY Brunswick
Ms- 3 fri.-.44
(Street Name. Numbers. Community. Suaoivis*on. Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LANDS 1NG:
❑ Slope ❑ Valley IPMPIS Q Ridge Q Other
(check appropriate box)
LATITUDE 3 �(q 3 .j,� z-
(4,
w f � i>
LONGITUDE, `7, / . 0 2
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: p6S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form f not using GPS) e, ; pe
A,t,.• r
4. WELL OWNER A/4
OWNER'S NAME P. ivi+ ' ,
STREET ADDRESS 9e k j2t~L
P AIL I Y Y
City or Town State Zip Code
- ' 67
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
e( 3
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO.E''
c. WATER LEVEL Below Top of Casing:
(Use '+' if Abova 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): METHOD OF TEST19- PL.'
Fr.
f. DISINFECTION: Type 57—e -re l:1.Amount //
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
•
6. CASING: Thickness/
Depth Di� ejgr W�gtyt�,� � Material
From= To ' 2 Ft. I//��
FromTo Ft.
From ___ ToFt.
7. GROUT: Depth Material Method
RIB
From C To 40 Ft. 1 0.9° 1,',1'C Y.-2"
From To FL
From
To FL
8. SCREEN: Depth Diameter Slot Size Maternal
From i To Ft. / / " in. r,'j)
From To Ft. in.
From To
Ft
in. in.
SAND/GRAVEL PACK:
Depth S:ze Ma:eriai
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Descrpt,cn
IQ / . ' '
/9 - 2 3 rn /
-7,1 — 7 7 cL._otv
9 3 — i I oit, :rz .1' e, - k tf c I- - 0 41
11. REMARKS:
•
DEC
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I DO HEREBY CERTIFY THAT THIS WELL wAS CONSTRUCTED N AcCOROANCE WtTH,,
15A NCAC 2C. WELL CONSTRUCTION STANCAROS. AND THAT A COPY OF THIS t. '`;
RECORD HAS BEEN PROVIDED T THE WELL OWNER_
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SIGNATCJRE OF CERTIFI WELL. CONTRACTOR
,41,. it° .774?-
PRINTED NAME OF PERSON CON TRUCTITHE WELL,,
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.
Form GW-la
Rev. 7/05