Well CompletionHAR1' "'T DEPARTMENT OF PUBLIC HEALTH RMIT
TO C-NSTRUCT A DRINKING WATER SUPPLY ✓ELL
PIN Parcel 06 1505 0006 04 Application 11-5-28130 Subdivision:
Applicant Name: Larry Dauehtry
Address: 801W Cumberland ST DunnN.C. 28334
Type of Facility Served by Well: SFD
Sewage System: 25%
Permit Conditions:
Lot 1
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 Agent„_ Date 1-17-j7-
Grouting Inspection Witnessed Date
❑ Grouting self-certified by driller GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application - Well Contractor:
Applicant 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)
From To
From To
From To
Inspector:
Remarks:
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Well Head Information
Casing Height: (above finished grade) / Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: / Sampling Tap: Backflow Preventer:
Sample Taken? <es E] No Well Head properly sealed:
Remarks:
Authorized State A nt Date '~s~
See Attachment for completion sketch
Application Yk 5-28130 Applica Tame: Larry Daughtry Subdivision:
Well Construction Sketch
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Well Completion Sketch
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Lot 1