410445_Well Construction - GW1_20130211

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water 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
CiN IX Town State
[phone]
Area code- Phone number
2. WELL INFORMATION:
Zip Code
SITE WELL ID #(if applicable) 0 0 7 / S ,)
STATE WELL PERMIT#(if ap icable)
P RMIT �If a 'igaebt)
DWQ or OTHER i �P
i
WELL USE (Check Applicable Box): Residential Water Supply.'
DATE DRILLED /] 2 tz'
TIME COMPLETED / =f `� AM Q PM
3. WELL LOCATION:
CITY: , ,,:1,0,. t COUNTY Brunswick
91/ / 674.p 3';#1,1 L'a ee,r eLkI41
(Street Name. Numbers. Community. Suao:vrsion. Lot No., Parcel. Zap Coae)
TOPOGRAPHIC / LAN ETTING:
0 Slope °Valley grim 0 Ridge ° Other
(check appropriate box)
9 Ir IY LATITUDE 3 0 /
LONGITUDE
Z:7,1-06
May be in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source:'S °Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
C; ti t (94 ip <,(4,44, 424
C bj
State Zip Code
c-79 /I )
Ar code - Phone number
OWNER'S NAME
STREET ADDRESS
City or Town
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES Q' NO 0
c. WATER LEVEL Below Top of Casing: i
(Use '4-* if Abova Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): `3METHOD OF TEST /9
Fr.
f. DISINFECTION: Typefrer0e14 Amount / 0
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
Depth
From 0 To Ft.
From Si To Ft. / by
From To Ft.
Diameter
To
To
To
Thickness/
Weight
.- 4 Rio
7. GROUT: Depth Material
Y �
From 0 To10 Ft. t, nfr 4
FromTo FL
From To FL
Material
Method
vR f,1
8. SCREEN: Depth..., Diarn+ear Slot Size Matenal
From S.—To j— Ft. ( l f in. / in.
FromTo Ft. in.
From To Ft in.
. SAND/GRAVEL PACK:
Depth
Frorn To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
6,10- y
11. REMARKS:
Size
Ma:eriai
Formation Descnptccn
r� racy � ev9-,6a,
-k•iivip
vtl
2
f
l 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T. E WELL OWNER.
SIGN URE OF CERTIFIED 1 CONTRACT E '`` � GATE
Fa { 13
cvB
PRINTED NAME OF PERSON'CONSTRUCTIiv T E WELL
r: 01
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-1a
Rev. 7/05