412214_Well Construction - GW1_20130311

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rt = r'a RESIDENTIAL WELL CONSTRUCTION RECORD
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t 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 WellDrilling
Well Contractor Company•Name
STREET ADDRESS P.O. BOX 39
Shallotte, NC 28459
(910) 7
Cily a54-9Tam 311State
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID # if a Iieable) 24/ fl
t PP
STATE WELL PERMIT#{if applicable)
DWQ orOTHER PE �# I 2/* 009
WELL USE (Check Applicable Box). Residential Water Supply D
DATE DRILLED Z- 13
TIME COMPLETED - O
3. WELL LOCATIQN:
CITY: -j COUNTY Brunswick
692, "96-1. 62-1 u-ss ,r0-01,4
0441
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
❑ Slope p Valley p Flat p Ridge D Other
(check approprie box)
LATITUDE 3 O P ,r ‘gyv
LONGITUDE _211" 3 if, 6 2..3
Latitude/longitude source: D GPS DTopographic map
(location of wed must be shown on a USGS topo map and
attached to this form f not using GPS)
4, WELL OWNER
OWNER'S NAME (r)Qrfl 0 i 5
AM O PM 12?''"
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS 6t9 / 7 rr -wh ey. V"
5ii- c Y
City or Town State Zip Code
/3 (4,
Ar - - code - Phone number
5. WELL DETAILS:
‘10
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES�NO 0
c. WATER LEVEL Below Top of Casing:
(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 (gpm): METHOD OF TEST
Y
FT.
412214
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
�-:AL Amount
id
From
From
From
To
To
To
Thickness/
Depth - Diankter W eight
From, V To .›A Ft. .
From To Ft.
From To Ft.
Material
7. GROUT: Depth Material /g Method
From G To 2 Ft. (A , C/v.i4
From To FL
From • To Ft.
8. SCREEN:pth
From ' To 70
From To
From To
SAND/GRAVEL PACK:
Depth
From s, To
Frorn To
From To
10. DRILLING LOG
From To
3 — c/a
f/ a 7
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1 L� , `tii1 Yc,
Di. y Slot_S M t
Ft. �n. / In. l
Ft. in, in.
Ft in. in.
Ft.
F.
Ft.
Sze Ma:erial
Formation Descnptlon
c
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MAR 1 Mi-N :- q ?Oi]
11. REMIKS: WATOUALITY SECTION
BY: -- INF-ORMATION PROCESSING UNIT
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 14 ACCORDANCE WriH
15A NCAC 2C. WELL CONSTRUCTION STANCAROS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO E WELL OWNER.
4/1 /
SIGNATURE OF CERTIF1�.i. ELL CONTRACTOR
y
/Ug1u Tgc
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center—[phone] ext 568. 9
Raleigh, NC 27699-1617 • Phone No.
Form GW-la
Rev. 7/05