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NEW WELL COMPLETION
HARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT TO CONSTRUCT A DRINKING WATER SUPPLY WELL 17--5-- PIN #: Parcel #: Application #:7)0-9 (ti- Subdivision: Lot #: Applicant Name: fil lfy� (�,.� Address: 4 3 ( fJ � , 04 l)t;Ntj rj, Q. , Z 3,j Type Type of Facility Served by Well: SFD Sewage System: r' r SOr-,%� 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 G 4V-4r -- O'�"`rt Date Grouting Inspection Witnessed Date _ ❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ Nc See attachment for construction sketch r —i WELL CERTIFICATE OF COMPLETION Date: A Application #:Tga "'L Well Contractor: Applicant Name: Address: L,31 ►- -7'-- � (Lid 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) Casing 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: Remarks: On Hold Date: _ _ Release Date: 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 %- iC -13 See Attachment for comple ion sketch Application #: Applicant Name: Subdivision: Lot #: Well Construction Sketch z Well Completion Sketch Norilt Carolina - Depatt neut of Envitoffiuoat and Natural Resources - Division of V WELL CONTRACTOR MWIYIDUAL) NAME (wb* I.aM Williford WELL CONTRACTOR COMPANY NAAIR I.aao[v Willifcnd' -Well 2dhag STATE WELL CONSTRtlmm !&itlY m OCIATEn WQ 1. WELL USE (Check Applicable Box): Residential MunicipaliPublic O Monitoring 0 Recovery 13 Heat Pump Water jection O Other 0 1 2. WELL LOCAAkjQv--q NOR" Town: kn A County LKJe (Serest Nun% Numbiok Community, &66viatao. lot No., zip Cello) 3. OWNER: (n ar 1`l it S m a;i4 e rJ $ Address -- s Latittid (saun a Routs No.) ©yonh N'G {1g33� City or Tows Sam zip Cods From Ayes and@- Phms number 4. DATE DRILLED S. TOTAL DEP`M -�'�5 — 6, DOES WELL REPLACE EXISTING WELL? YES o NO 7. STATIC WATER LEVEL Below Top of Casing: . ttln N- if Above Top of Casino 8. TOP OF CASING I3 I FT. Above Land Surface* °Tev eioaslae ttrlatweted ot/or below rand sorb a ngvites ■ vadww= is arcordnc"� wM 1SA NCAC 2C .0138. 9. YIELD (fpm): _ L6 METHOD OF TEST_ ►col -- 10. WATER ZONES (depth): a (6 -3L 11. DISn*MCTION: Type 12. CASING: AmuUnt ' 12 Cap Show dir Wa11 Twdma;x two State From_` To -I--- From— To Fes_ FromL, To Ft 13. GROUT: Depth Mme_ Mexhod Frost, To— FL 14. SCREEN- nmmh Muncte From- �6 TF4.....£�_3a• Sl M �-. is —�= From, To 1S. SANDJGRAVELPACK: Depth Sim Mad u41^ Front--TO—Ft,—�.—. 16. REMARKS: Da n r\ I DO HEREBY aRTE Y THAT THIS WELL WAS CONS MUCIM IN ACCORDANCE coNmLCnON STANDARDS. AND THAT A COPY OF THIS AD HAS BEEN P n.A.wR w.w nwY'tnl.Mt lidTDii r'i 7T.M UMI Submit the orhanal to thn Division of Water Quality. Groundwater Seedon, 276d9.1636?boaa Na. (919) 733.3221, within 30 days. Quality - Groimdwsler Section TTON AAM- enoNz s Qlib 567 - 2579__ ■ �■I Liao Use gVVhicdLvnd aettfi E3Slope (]Valley �Flot ( dam d=) %nonglieide of well location L un as and distance in miles 5otn at least ®ds or County Roads. Include the road comsrwtr road mme:s. x4ioe►1 fi Sensw? 1 SA NCAuC 2C, WELL 12D TO THB,WI'.t.L OWNER 1� -6 Ix Mau &Mee caste - R11012h, NC GW 1 REV. 07r=I