412213_Well Construction - GW1_20130311

c. WATER LEVEL Below Top of Casing:
(Use'+' if Abovv 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 actor ce with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST `Y"-'
RESJDENTIAL 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 or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:.
SITE WELL ID #(if applicable)
yjrP
STATE WELL PERMIT''#{-.ii applicable)s
DWQor OTHER PERMIT /4'Me)c 6lA 3 2,t L 7-
O E ,
WELL USE (Check Applicable Boy: Residential Water Supply Er
DATE DRILLED ! r
TIME COMPLETED 1 ,
3. WELL LOCATION:
CITY:
S w 6-)F/y
AMO Pm Er'
COUNTY Brunswick
-6/1 pie-19.-/e
(Street Name. Numbers, Community. Suaa:vision,
TOPOGRAPHIC / LAND SETTING:
° Slope ° Valley [e lat ° Ridge ° Other
(check appropriate box)
LATITUDE 3 3 WI"
LONGITUDE _6.-
Latitude/longitude source::6)4/PS °Topographic map
(location of wed must be shown on a USGS topo map and
attached to this form f not using GPS)
Lot No.. Parcel, Zip Coae)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town
{ Il }- 7'
State
7-9 t,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
/ V 4 rarA/Y1 ei-ce
.3-6/ 41)-#-e 51)
V‘ z
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES NO 0
1
FT.
412213
f. DISINFECTION: Type__
g. WATER ZONES (depth):
From To From To
From To From To
"ie iC Amount / 0 2--
From To From To
6. CASING: Thickness/
Depth Diamgter Wei ht Material
'
From To 2 Ft. `I : '::ate, 77 lia eve -
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
Frorn C To C Ft. 63F'tA«'' )' (IAri►
FromTo FL
From To. FL
w
8. SCREEN: Depth, Diameter, Slot Size Mfrtenal
�
From ." To , Ft. 1 yln. , 0 % 2in. r 4" 4--
From To Ft. in. in.
From To Ft in. :n.
9. SAND/GRAVEL PACK:
Depth
Frorn To
From To
From To
Ft.
Ft.
Sze Ma:erial
10. DRILLING LOG
From To Formation Descrptivn
5 e4-k'
c L ot
2-/ .T 6 I, /1/17
11. REMARKS:
e L 7
5/A'p oper
MAl m 4 1...
v4 TFF OIJA)JTY SECTION
INF ATIOrN PRESSING UNIT
�3p� OC
J�qq (t1_jj i+W`�L�Tf?� `�Iri.n,Ryf•L^�f .f:, �� v
AR 2013
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANCI•RDS. ANO THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0`' /SY/3
SIGNATURE OF CERTIFIED E1 CONTRACTOR DATE
fi-DO ia 17Z ..
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. (919} 733-7015 ext 568.
Form GW-la
Rev. 7/05