New Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 12- 5- 30028R Subdivision: Walts Crossing Lot #: 1 I
Applicant Name: Roxanne Helen Boyce
Address: 201Edna John Ct Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
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 j
g ' %,.� ,a�1rFr.� Date ! Z- y —/ Z
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? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Age , Date %Z- Z1-i7-
See Attachment for comp3'etion sketch
Application #:12- 5- 300288
Well Construction Sketch
Applicant Name: Roxanne H BOYCE Subdivision: Walts Crossing Lot #: 11
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Well Completion Sketch
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DEC- 19- 2012(WED) 14.58 BILL5 TELL DRILLING -f � -k -�, P-6 � I ab q it 2--
t ESIDEN7= WELL CONSTRUCTION RECORD
'orth Carolina Department ol'Environmentni and Natural Rcsourecs - Division of Watcr Quality
CERTIFICATION 3467 -A
1. WELL CONTRACTOR:
Bill's Well Drilling
WELL CONTRACTOR (individual) NAME
Michael Nanney
STREET ADDRES300 McArthur Rd
Fayetteville, NO 28311
(910) 480.3740
2. WELL INFORMATION:
WELL ID 9
State Well Permit #
Other Permit 12•S- 30028R
WELL USE Residential
DATE DRILLED 12/18/2012
TIME COMPLETED 4:00 PM
3. WELL LOCATION:
City Dunn County Harnett
>.Ot Edna John Ct Dunn 29334 Lot
Street Name, Numbers„ Community, SUbdlvislon, Lot No. Zip Coda
TOPOGRAPHIC / LAND SETTING:
Slope
LATITUDE / LONGITUDE OF WELL LOCATION:
Latitude/Longitude Source:
(location of well must be shown on a USGS topo map and
attached to this form If not using GPS)
4. WELL OWNER•i, /
OWNER'S NAME Clayton Homes
STREET ADDRESS 3340 Gillespie St
Fayetteville NO 28306
Area code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 240
b. DOES WELL REPLACE EXISTING WELL? No
e. WATER LEVEL Below top of Casing: 73
d. TOP OF CASING IS 1 FT Above Land Surface*
9. WATER ZONES (Depth)
From 205 To 215 From To
From To From To
From To From To
6. CASING:
1
Topsoll
Depth
Diameter
From
1 To
170 Ft, 4.5
From
To
Ft.
From
To
FL
7. GROUT:
Depth Material
From
0 To
3 Ft Cement
From
3 To
24 FL Bentonite slurry
From
To
FL
B. SCREEN: Depth
From To
From To
From To
P. 001/001
Thickness/
Weight Material
sdr17 PVC plastic
Method
Poured
Pumped
Diameter Slot size
FL in. in
FL In. In
FL in. In
9. SAND /GRAVEL PACK:
Depth
From To FL
From To Ft.
From To FL
10. DRILLING LOG
From To
0
1
Topsoll
1
2
Oranga Clay
2
12
Tan Banc
12
1s
Orange Sandy Clay
is
20
Orange Sand
20
36
Orange Clqy
as
135
Gray Clay
135
160
Green Clay
160
165
Gray Rock
1e6
240
Black Rock
Al. REMARKS:
Size/ Material
Formation description
Materlal
100 HEREBY CERt7FY THATTHIS WELL WAS CONSTRUC1t:D tN ACCORDANCE WITH
(Use " +" If Above Top of Casing) 15A NCAC 2C, WELL CONS=CrION STANDARDS, AND THAT A COPY OF THIS
m Top of casing terminated at(or below land surface requires a
RECORD AS I PRO ED l rHE WELL OWNER
variance In accordance with 1SA NCAC 2C.0118. 12/182012
e. YIELD (gpm): 18 METHOD OF TEST Air SIGNATURE-
f. DISINFECTION : Typ -HTH Amount 1 Michael Nanney DATE
Submit Cie orlpinal to the Dlrlelon or Water quality within 30 days
Ann. Infomusion Mgt, 1617 Mall Service Center— Raleigh, NO 27SWI017 Phone No, (910) 733-7016 eat 560.