415226_Well Construction - GW1_20130812

RESIDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATIO
N # 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 aTown State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) 2. ' % . �G / i OPq /
STATE WELL PERM ' ap icable)
DWQ or OTHER: `IT it � c Ie / r 7 P # P` .. 2E
WELL USE (Check Applicable ox): Residential Water Supply Er -
DATE
DRILLED 2 )///3
TIME COMPLETED ) ,Z3 0 AM O PM 11f"
3. WELL LOCATION:
CITY: f,44),4 COUNTY Bruns`Wick
e ithitaj a/
(Street Name. Numbers, Corn unity, Suoo,ws►on. Lot No.. Parcel. Zip Coae)
TOPOGRAPHIC / LAND SETTING:
°Slope O Valley lac ° Ridge Q Other
(check a.pproprt a box)
LATITUDE 3 3 28
LONGITUDE 719
7- 2-
Latitude/longitude source: o' 1 S °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form f not using GPS)
4. WELL OWNER
OWNER'S NAME ,5 i' flu
May be in degrees.
minutes. seconds or
in a decimal format
STREET ADDRESS
r.
City or Town
( fa }* 53 Yji.Y
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
P-) v4it_We)N
Me, /-14740
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use `+° if Abovwa 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): /2V METHOD OF TEST /'L
f. DISINFECTION: Type
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
Dept
From ( To
From
From
To
415226
To
Amount ,_..7/ 0'.....
From To
From To
From To
Thickness/
Diamoer Weight Material
Ft. JCL >a -&--
Ft.
Ft.
7. GROUT: Depth
From -_ To___ -f__. Ft.
FromToFt.
FromTo Ft.
Material
Method
itti17
8. SCREEN: Depth Di r Slot Size
From3'rTo3'7Ft. Yin. 4071.. in.
From To Ft. in.
r
From To Ft in. in.
. SAND/GRAVEL PACK:
Depth
From. To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
S:ze Ma:eraal
Forrnaticn Descrptcn
et4 tkC ifi4"))
c�
y tt W •4+n� tat -�.
iLtr.�3* tits,,.
ri
11
i..• i i .av .
1 DO HEREBY CERTIFY THAT THIS WELL -WAS 'CONSTRUCTED 1,4 ACCORDANCE WtTH-
I SA NCAC 2C. WELL CONSTRUC • N STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED . E i"E+ +M OWNER.
7/1/3
SIGN URE CER IED WELL %NTRACTOR DATE
g?t1
)1Sat-
PRINTED NAME OF PERSON CONSTRUCTING THEWELL
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