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NEW WELL COMPLETIONHAR fT DEPARTMENT OF PUBLIC HEALTh -�RMIT TO CONSTRUCT A DRINKING WATER SUPPLY WELL PIN #: 1505 -07- 6048.000 Parcel #: 061505 0006 Application #: 13 -5 -31906 Subdivision: Applicant Name: Signature Home Builders Address: 801 West Cumberland ST Dunn N.C. 28334 Type of Facility Served by Well: SFD Sewage System: 25% Reduction Permit Conditions: Lot #: 2 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 Ag t Date $ -L<?- I Grouting Inspection Wit essed Date r-1 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: 1 T3 (above finished grade) Access Port: Vent Stack: Well ID Tag: Pump D Tag: Sampling Tap: / Backflow Preventer: Sample Taken? F-1 Yes E? No Well Head properly sealed: Remarks: Authorized State Age Date 7 See Attachment for comp ion sketch Application #:13 -5 -31906 Applicai ame: Signature Home Builders Subdivision: Lot M 2 Well Construction Sketch A VC I i .Zip `1 D 1 �a Well Completion Sketch OAgricultural OMunit Wftblic OCiaothe UW 0101tiOSON lioSSupp1Y) )dRaWWfiQ1 WOW Supply (9001e) Olndustrumcommemial OResideutial WAw Supply (shared) OAquifer Redhup OGroundaatea Remodiatioo OAquifor Stotts and RMOMY OSalioitY Hama OAquifer Teat OStomtwaer Dtainep OExperimmntel TalmoloU OSubsldehhoe Cant 00cothermal (Closed Loop) t7fracer 00eothecmd OWWAKAft Rom ) 00ther :alder 021 Remake 4. Date weil(s) eeapicaw. '•+"� ""� I S. Well IAM* door �A beret, F-4riPY' Faeilit 40woer Name IF -Aity Qm (if wU-bk) _ 0-6 ray .Phydert) Ad&ws, City. and Zip ffg rn e cwmw urea! 16"fieaim M. (M) �m � �A Im MIMI ".'Jwr tM•L�1'�� �Q � M 1 �.I ©mia� '�.JI' Lea: ��'L�at' �•" f.`�LT�;`. `�.`T'i� �t�l� ;i'►�i..a.?Lr�� sty i�r;z -rte tt. ti oil' 1 1A ndj 4 /a SC4 n ✓t C /";t 7. —Dr- 5b. Latitude and Lo4lade In degreesiWaskahmod4le or dodmd degrees: 2L Certification: (if well field, = httVWg bb solkiW) 6. is (are) the welt(s): OPermamat or OTemporary py=44 s f=' ! Y «nom d on die.elr(irj nor fwa+'>r o�nexrsd br wok iSA c OJC .Of av 13A AcW 02C.0200 p'dt Caaarcrwn ,2 and der 0 cW oj'dds icco►dkat pvW"%gk" well 0ntvr. 23. Site dingrank or dldonal well details: You may use to of this page a provide addftimd wall site dowls or well crosntw um Mails. may also atcrth WdItIonal peon if 24. Submittal 1 24a. For An Wdh 1! Submit this fmo within 30 days of of well a so tlhe fW ng: DlvLbo Water Qaallgr, den Unit, 11619 &rules Ceshter, w NC 27699.1619 246. For :chewier about, also submi ewAttuetion to tee Dividoa 13. FOR WATER SUPPLY WELLS ONLY: 16M 13a, Yield Won) / t/ Method at Wt: ?,A the For Water alai the address(es) abc completion of well 13b. Diefa[eetloa ypc: _� A t: u' where constructed, In addition to naft the Ehtm to the address in 24a of this Eton within 30 days of completion of gull Quality, Ua ad 1*cdn Control Program, 1 Service Ccatwr NC 27GW16M 14 U Maermat WeID: in amutois w 3ckmad um [hxm m ■Ira submit otte copy of this Etrm within 30 days of sbuction to the County health ftpartmmt of the county Form OW -1 tlanb C+atotioa n p I of Envkwm m aed mom Reeoamw —Di+ = of Water QW* gvv.6 i hn. 2013