414029_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
. City Town State Zip Code
[phone]
- Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 19‘ ° 0
1*/ 3 9T-A
STATE WELL PERMIT#0,”plicable)
DWQ or OTHEF71EMTV(Vagtble) zfue ooz.
WELL USE (Check Appli le 132.): Residential Water Supply Er-
7•DATE DRILLED kr ,, / i / 3
TIME COMPLETED /: I) (-) AM 0 PM
3. WELL LOCATION:
- CITY: 4.0 it, (1404,6 IP
COUNTY Brunswick
22.4 e IfaCt L stif
(Street Name. Numbers. Community. Suoonnsion, Lot No.. Parcel. Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE ?4'
LONGITUDE (/2.C9/20-'
Latitude/longitude source: oGPS °Topographic map
(location of well must be shown on a USG$ topo map and
attached to this form I not using GPS)
May be in degrees,
minutes. seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME itteir1 olife
STRE ADDRESS Pb 3 K
C
City or Town State
gI 3 is 51) 56,
• Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Its"'
'Ptlev;'ff/I
• 1Yf
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ar.."1-rl:0
c. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top4of 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 (gprn): 4..." METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
414 0-29
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weght Malgrial
..
From 6) To .3 S--- Ft. 2 .3%1 h
From To Ft.
From To. Ft.
7. GROUT: Depth
Frorn 1) To 0-0 Ft. 6Cfi .14/
Material
From To FL
From To FL
8. SCREE
From
From To Ft. in.
To Ft in. in.
ept
To
Diarnetyr Slot Size
Ft.
From
Method
0
9. SAND/GRAVEL PACK:
Depth S:ze
From To Ft.
From To Ft.
. From To Ft.
10. DRILLING LOG
From To
1— 22-
- 5 3
'33-LJf
t)
11. REMARKS:
Ma:eriai
Formation Descr.ption
3 4f
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BY:
!t"
INFORMAMN PRO
13
WATER' QUAL11 'ETON
ESSING UNIT
100 HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WTH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO WELL OWNE
SIGN
IED WE' ri• TRACTOR
Is-i<3
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