414027_Well Construction - GW1_20130610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICA2942
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 Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) ,,��1) 3 3 S3'
STATE WELL PE Mali -f -. ppkcab! )
DWQ or O T R PER IT (if l'peptcable) / 000
O {
WELL USE (Check Appli I Box). Residential Water Supply 9"
DATE DRILLED Y,7/& /5
TIME COMPLETED ' 30 AM 0 PM Qom`
3. WELL LOCATIO
CITY: t�Q! 0 /24"
CITY: If
.? 57-064 trig
COUNTY Brunswick
�y
(Street Name. Numbers. Commune . Sua nnsson. Lot No.. Parcel. Zip Cooe)
TOPO RAPHIC / LAND SETTING:
ii•Wope °Valley ❑ Flat 0 Ridge °Other
(check appropriate box)
LATITUDE 3 7 55,
LONGITUDE
Latitude/longitude source: PS °Topographic map
(location of wee must be shown on a USGS /opo map and
attached to this form I not using GPS)
May be in degrees,
minutes. seconds or
in a decimal formate
4. WELL OWNER
OWNER'S NAME
£i//% 15e1/
STREET ADDRESS 4,7 CD C it ri ► f
5_ 'at*
��
City or Town State Zip Code
p3/- 3r
Area code Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 - NO Er-
c. WATER LEVEL Below Top of Casing: ,�' FT.
(Use '+' 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 m : 51
l9R 1 METHOD OF TEST
f. DISINFECTION: Type3;""eff-a- k /il - Amount 0 2.-
g. WATER ZONES (depth):
From To From To
From To From To
From To From To •
6. CASING: Thickness/
Dept ,,,...- Diameter We ht Material
From To Ft. 7 6. St if Ya de v>
From To Ft.
From To Ft,
7. GROUT: Depth Material Method
From CTo ' Ft. ,,s1 Aj'e tom.
From To FL
FromrTo FL
8. SCREEN: Depth Dlarnete Slot Size Matenai
�'
Fromys � Ft. / n. /n.
From To Ft. in. in.
Frorn To Ft in. in.
9. SAND/GRAVEL PACK:
Depth S:ze Ma:erial
From To Ft.
From To • Ft.
From To Ft.
10. DRILLING LOG
From To Formation Descnptlen
0 ' lit ., pr. ....:/
9 -°- L . ,
-> ....., 1 2,... - ' 1 19 /UV
1'7 — i'T 2-- C et., 4- 7
3' - — Ai"
z/,/ CL.- 617
,,
., , 5,!,
, 61 1::-. r.) 0 i')
c I' 4
A ^`
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH -
15A NCAC 2C. WELL CONSTRUCTION STANCAROS. AND THAT A COPY OF THIS •
RECORD HAS BEEN PROVIDED THE W 4' OWNER..
7
- 6 /3.
SIG TURE OF CER FI-. ' ELL CONTRACTOR . DATE •
- ' 4:$ ° Pi') .-. vi,,, pi , a L
PRINTED NAME OF P RSON 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-1a
Rev. 7/05