New Well CompletionHA ?,TT DEPARTMENT OF PUBLIC HEALY ERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0598 -76- 5994.000 Parcel #: 07 0598 0126 01 Application #: 12 -5 -29662 Subdivision: Lot #: 1
Applicant Name: Barry Caulder
Address: 130 Redrobin Dr 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 Agen �, Date
fl-N��
� rr.� el -1
�__
Grouting Inspection Witnessed Date
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: , Jb f j Application #: 'Z 5 2 Well Contractor: W14(1:4vv C/.
Applicant Name:
Address:
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To
From To
From To
Inspector:
Remarks:
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Top of Casing is
in. above
surface. Yield:
gpm at ft.
Amount
Casing
Grout
From To
From 0 To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
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 0 No Well Head properly sealed: /
Remarks:
r �
Authorized State Age Date 'I-t8-t3
See Attachment for compl tion sketch
Application #:12 -5 -29662 Applic _name: Barry Caulder Subdivision: Lot #: 1
Well Construction Sketch
Noah Carolina - Department of Envh msent and Natmal Resources - Division
WILL CONTRACTOR (ITiDiMAUAL) NAME (Vd-t) Larry Williford
WILL CONTRACTOR COMPANY NAME .= Williford's Well Drilline!
STATE wa:LL CONSTRUCTION PZRMM TZD
1. WELL USE (Check Applicable Box): Residendal Municipal/Public O
Monitoring E3 Recovery 0 Heat Pump Water liecdon O Other ❑ 1
2. WELL LOCATION-
Nearest Town: � � n ri ty Harne#-
I
'OWL-A.-
(3u-a Nome. Numbcm CammemW. &" Adam, Lst No, Tap Cod°)
3. OWNER: a JdC ,
Addtoss IA jle _ Ad
Latituc
(84aee ex Routs Na)
�Hnrl ��3s'
NG
g
City aTown sew Zipowe
From
,�. node. pease aeembar / 3
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
_
7. STATIC WATER LEVEL Below Top of Casing:
(Veo'w° If Above Top of C+e
S. TOP OF CASING IS l FT. Above Land Surfacu>O e*
•Top of dada` termismad odor below la-d e- 6m mgWm a
vadaact b a wrda-ea with LSA XCAC 2C .013L
9. YIHLD (6Pm): I METHOD
F T ST
10. WATER ZONES (depth): � fe- -
11. DISINFECTION: Type-4EK= Amount a
Show dim
12. CASING: Wall Thidmeaa two Sftw
From T.3-- FL !W aumbeus
From!._,... To Ft- - _
Fmtn!____ To Ft.,- .__..._
13. GROUT' Depth bbterw Meted
Tom ' f1t/ '0' bu
E��ETO-jji—)Ft &Utoiye —lam Y G Y'
�
14. s��p�
Fro 4 To � Z u' D2 im
From.. To FL----in. ;a
I5. SANDIORAVEL PACK
Dc
From A0 To SQ
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT 7MS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STANDARDS, AND THAT A COPY OF TkHS RECORD HAS BEEN P
orij
Submit the exlalnal to the Divlalon of Water Quality. Groundwater Setctlou,
276991-1636 !bean Ne. (919) 733.3321, within 30 da,7a.
Quality - Groumdwatw Section
CATION 6.2863
tnoNx o 0101567 -2579
■ r
List Use
chic land seft ag
qm Malley Mat
ibxlc of well location
m and disraaoe in miles fiom at least
mb or Cmmty Roads. Include the road
common road names,
1 SA NCAC 2C, WELL
BBD TO TEMWBLL OWNER
FAU13 j
Service Center - Rddgb, NC
OW-1 REV. 078001