414031_Well Construction - GW1_20130610

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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
own State
(9107mT 754-9311
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID applicable) IC; 07,n1J
STATE WELL PERMIT#V applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box), Residential Water Supply 0
DATE DRILLED 5 / 2'41/2
TIME COMPLETED il .19 e' 170
AM 0
3. WELL LOCATION: i
CITY: 51" tePe COUNTY Brunswick
•2.133
(Street Name. Numbers. ornmunity. Subonnsion. Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
Slope (Valley err5 DRidge 0 Other
(check appropriate box)
53/ 641-
LATITUDE •3
LONGITUDE
May be in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: Dell.' °Topographic map
(location of we, must be shown on a USGS topo map and
attached to this form I not using GPS)
OWNER'S NAME 04, 711alui 45-5;x;-)4•.
4. WELL OWNER
STREEVDDRESIS -7- '1;79 /411
"LIM /7 /14-1
State Zip Code
( 9.0 )- Lb) *I- /1644 •
City or Town
Area code • Phone number
5. WELL DETAILS: /
/IC°
b. DOES WELL REPLACE EXISTING WELL? YESNO 0
c. WATER LEVEL Below Top of Casing: ( .5 FT.
(Use '4* 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 (gpnn): METHOD OF TEST
a. TOTAL DEPTH:
r
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
Depth
From U To L Ft.
Amount
To
To
To
•
Thickness/
Diameter ht Material
We.
?° 0 •-...ZE1
From To Ft.
From • To Ft.
7, GROUT: Depth Material
From Tot Ft. From
-
From • To FL
From To FL
B. SCREEN: Depth Diarnyr Slot Size
From To/CV--) Ft.)€4 in. ,PiZ--- in.
From To Ft. in. in,
From To Ft in.
. SAND/GRAVEL PACK:
• Depth
From To Ft.
in.
Sze Ma:erial
From To Ft.
From To Ft.
10. DRILLING LOG
From To
ir
Formation Description
5 )VAIP
—
,c 7
5:3
11. REMARKS:
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JUNA 2013
INFopl
trIA; r,
BY:
,.3
TION
SING UNIT
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrTH
15A NCAC 2C. WELL CONSTRUCTION STANCAFtDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE TO THE WEI& OWNER.
SIG
DA)
ATURE OF CERTIFIE»VELL CONTRACTOR DATE
IAA 17)00 tj
PRINTED NAME 0?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