410446_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
City or Town State
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#{d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box : Residential Water Supply 0
DATE DRILLED f / ) 2
TIME COMPLETED Lk +) 6
3. WELL LOCATION:
CITY: 19Gi e1 see COUNTY Brunswick
//72 Z.:,,cti
I-. Sea- 71/
Zip Code
AM ❑ PM Cr—
(Street Name, Numbe Community, Suoairnsion, Lot No., Parcel, Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
Q Slope [Walley ❑ Flat Q Ridge ❑ Other
(check appropriate box)
LATITUDE 3 3_ 5 T, 2-2-1
LONGITUDE A v 3 % q -7Y
Latitude/longitude source: Q ?S ❑Topographic map
(bcatbn of we, must be shown on a USGS topo map and
attached to this form m not using GPS)
4. WELL OWNER OWNER'S NAME 4, /)14,..1ervi e.
STREET ADDRESS
65t 11 Art_ 2— 9b
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
5-471-7c'85
Area code - Phone number
5. WELL DETAILS: — 1
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ('3NO ❑
c. WATER LEVEL Below Top of Casing:
(Use `+' if About: 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): f % METHOD OF TEST
it
f. DISINFECTION: Type )IYi7L Amount
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
From To
From To
From To
Thickness/
Depth' Dtareter WeigMaterial
From To_ Ft. Z- ht�. lorL-.
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From To Z 0 Ft. 13.ii7bAr I Dir`Z _6 pi. v•
FromTo FL
From To Ft_
8. SCREEN: Depth Diame! Slot Size M tenai
From 3 7 r To Ft. 1` `�in. r /4fl. L.-
From To Ft. in.
tn.
Frorn To Ft in. in.
SAND/GRAVEL PACK:
Depth S:ze Ma:eriai
Frorn To Ft.
Frorn To F t.
From To Ft.
10. DRILLING LOG
From To
s"r
11. REMARKS:
Formation Descnpton
s 0}nt P
ifot
L
cr
DEC .2 }� 2072
•
I DO 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 TC'1E WEL: OWNER.
SIGNATURE OF CERTIFIED W CONTRACTOR DATE
PRINTED NAME OF PERSON C6NS WEIL
9S5
C 153 A
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.LO�