415225_Well Construction - GW1_20130812

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
Weil Contractor Company Name
STREET ADDRESS P.O. Box 39
Shallotte, NC 28459
(910)7
Cirya 54-9Tavn 31] State
Zip Code
Area code- Phone number
2. WELL INFORMATION: SITE WE L ID # if a licable I t)g5---r, 0 2 j I
1. { applicable) J
STATE WELL PERMIT#QI appli bte)
DWQ or OT R PERMIT#(if pP licabie) / 9
orf-e. PO r
WELL USE (Check Applicable Box): Residential Water Supply Q'
AT DRILLED `'' i
DATE
TIME COMPLETED / o v
3. WELL LOCATION:
/c,iL, COUNTY Brunswick
CITY:
AMO PMQ"'
(Street Name, tubers, Community. S . L F+ )
TOPOGRAPHIC / LAND SETTING:
0 Slope Q Valley 0 Ridge 0 Other
(check' appropnate box)
LATITUDE 3 f oi� 7 Y
LONGITUDEA IS
Latitude/longitude source: BPS oTopographic map
(location of wel must be shown on a USGS topo map and
attached to this form I not using GPS)
c*/ doitisr
t uooivtsion No. Parcel, Z� Cooe
May be in degrets.
minutes. seconds or
in a decimal format
4. WELL OWNER
I -j . ! %++let
OWNER'S NAME �� � l
STREET ADDRESS d'I T� F--t� _501-
e- d a I‘) y 3 t 0
City or Tovm State Zip Code
(&07 5 t:S
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: L/7
b. DOES WELL REPLACE EXISTING WELL? YES NO p
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS l 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 TEST
415225
f. DISINFECTION: Type 't_ Amount / i
g. WATER ZONES (depth):
From To
From To
From To From To
From To
From To
8. CASING:
Thickness)
Depth Diameter Wei ht Material
From, , To 3 9 Ft. a 6
FromTo Ft.
From To Ft.
7. GROUT: Depth Material From 0 To�F►. 'a I
FromTo FL
From To Ft.
Method
c-n Ixte,))7
8. SCREEN: Depth Diamet r Slot Size Mate i
From To 7) Ft. ix/yin. ,, 02--. in.
FromTo Ft. in. 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
0— )
5
69-711LA
ti
11. REMARKS:
Formation Descnptcn
5,01e44,9
<:i.Aj
t e_y
ere,oc,
I DO HEREBY CERTIFY THAT THIS WELL .WA -CONSTRUCTED P ACCORDANCE MTH
15A NCAC 2C. WELL CONSTRUCTION.S1 CARDS. ANO THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO fit+ 'WELL OWht£R.
SIG TURE 1'CERTIFIED :l CONTRACTOR
C1/3
DATE
/1' 11-XCAI „-4r
PRINTED NAME OF PERSON CONSTRUCTING THE 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