Well CompletionHARN DEPARTMENT OF PUBLIC HEALTH IT
TO C
TRUCT A DRINKING WATER SUPPL LL
PIN # 0589-29-7662.000
Parcel 07-0692-0163 Application 10-5-25146 Subdivision: Lot 1
ASklicant Name: Daryll Roberts
`4n 2466 NC 55W Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions: 100 foot off of Septic and Repair Areas
General Permit Conditions:
• Drinking water supply well construction must meet 15A NCAC 02C.100 rules
• The permitted drinking water supply well shall be located in accordance with the SITE PLAN
• ANY ALTERATION of the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State Age ' Date 9 /$'-I b
Grouting Inspection Witne se - Date -7-11-11
Grouting self-certified by dril GW-1 provided? a Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application Well Contractor:
folicant Name:
Address:
Directions to Site:
Use of Well: Date Drilled: Total Depth: Replacement Well? ❑ Yes ❑ No
Static Water Level: Top of Casing is in. above surface. Yield: gpm at ft.
Disinfection: Type Amount
Water Zone
(depth)
Casins
Grout
From
To
From To
From 0 To
From
To
Diameter: Material: Thickness:
Material: Method:
From
To
From To
From To
Diameter: Material: Thickness:
Material: Method:
From To
From To
Diameter: Material: Thickness:
Material: Method:
Inspector: On Hold Date: Release Date:
Remarks:
Well Head Information
Casing Height: / (above finished grade) / Access Port: Vent Stack:
Well ID`Tag: Pump ID Tag: if Sampling Tap: Backflow Preventer.
Sample Taken? Y s ❑ No Well Head properly sealed: ✓
narks
Authorized State A ent
Date y -/,7 -t 2
22~z -
See Attaclunernt for completion sketch
Application #:10-5-25146
Well Construction Sketch
Applican e: Daryll Roberts Subdivision: T of 1
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1 Completion Sketch