NEW WELL COMPLETION PERMITHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0684 -71- 0162.00 Parcel #: 04064 -0155
Applicant Name: Stan &Betty Trustman
Address: 10865 21 ON Angier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: CON
Permit Conditions:
Application #: 14 -5 -33169 Subdivision: Lot #:
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 i , C, s
Date
Grouting Inspection Witnessed Date
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
14 -5 -33169
Date: 4 / 1 / 14 Application #: Well Contractor: GRADY POOLE WELL & PUMP CO, INC.
Applicant Name: STAN & BETTY TRUSTMAN
Address: 10865 21ON ANGIER, NC 27501
Directions to Site:
Ilse of Well: RES, Date Drilled:4 / 1 / 1 4 Total Depth: 140 Replacement Well? ❑ Yes ❑ No
Static Water Level: _5 Top of Casing is 12— in_ above surface. Yield: 25 gpm at 140 ft.
Disinfection: Type HTH Amount 2 LBS.
Water Zone (depth) Casin Grout
From 0 To 135 From 0 To 125 From To 20
From To Diameter: 6" Material:GALV. Thickness: .188 Material: PORT. Method: GRAVITY
From To From To From SCREEMNGS
Diameter: Material: Thickness: Material: Method:
From To From To
Diameter: Material: Thickness: Material: Method:
Inspector: JAMES M. On HoId Date: Release Date:
Remarks
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 Aunt °– Date 3 '�
See Attachment for compl6n sketch
Application #:14 -5 -33169 Applicant Name: Stan & Betty Trustman Subdivision: lot ##:
Well Completion Sketch
0
.o
rte;
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1. WELL CONTRACTOR:
Felton Jacobs
Well Contractor (Individual) Name
Gradv Poole Well & PUmD Co Inc
Well Contractor Company Name
5809 Farm weWell Road
Street Address
Raleigh NC 27610
City or Town State Zip Code
9r 19) 266 -2185
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 14 -5 -33169
OTHER ASSOCIATED PERMIT #(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Nr
DATE DRILLED — !�
TIME COMPLETED 9,00 AM ❑ PM
4. WELL LOCATION:
E'S`MEATUL
• r+x
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
10865 21 ON
WELL CONTRACTOR CERTIFICATION # 2765-A
1. WELL CONTRACTOR:
Felton Jacobs
Well Contractor (Individual) Name
Gradv Poole Well & PUmD Co Inc
Well Contractor Company Name
5809 Farm weWell Road
Street Address
Raleigh NC 27610
City or Town State Zip Code
9r 19) 266 -2185
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 14 -5 -33169
OTHER ASSOCIATED PERMIT #(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Nr
DATE DRILLED — !�
TIME COMPLETED 9,00 AM ❑ PM
4. WELL LOCATION:
CITY: Anaier
COUNTY Hamett
10865 21 ON
27501
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat
[]Ridge ❑ Other
LATITUDE 36 °_'
" DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75
" DMS OR 7X.XXXXXXXXX DD
Latitude /longitude source: ❑GPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Stan & Betty Trustman
Owner Name
10865 21 ON
Street Address
Anaier NC 27501
City or Town State Zip Code
9( 19 ) 538 -8111
Area code Phone number
6. WELL DETAILS: p
a. TOTAL DEPTH: J�
g. WATER ZONES (depth):
Top 0
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
a variance in acccorda� with 15A NCAC 2C .0118.
SIGNA tE OMERTIFIEDYJELL CONTRACTOR DATE
e. YIELD (gpm): _,e .� METHOD OF TEST BIOw
Thickness/
7. CASING:
Depth
Diameter
Weight Material
Top 0
Bottom jad-- Ft. 6"
Jz#J
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material
Method
Top 0
Bottom 20
Ft. Portland & Gravity
Top
Bottom
Ft. Screenings
Top
Bottom
Ft.
9. SCREEN: Depth
Diameter Slot
Size Material
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft. in.
in.
10. SAND /GRAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top B ft
0 /
/
/
/
12. REMARKS:
Formation Description
Topsoil
�e
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT.
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use " +" if Above Top of Casing)
STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN
PROVIDED TO THEW L OW
d. TOP OF CASING IS Cane FT. Above Land Surface-
*Top `Top of casing terminated at/or below land surface may require
/14
04/j/14
a variance in acccorda� with 15A NCAC 2C .0118.
SIGNA tE OMERTIFIEDYJELL CONTRACTOR DATE
e. YIELD (gpm): _,e .� METHOD OF TEST BIOw
_ Felton Jacobs
f. DISINFECTION: Type HTH Amount 1 Ib.
= PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Infonnation Processing, Form GW -1a
1617 Mail Service Center, Raleigh, NC 27699 -161, Phone: (919)
807 -6300 Rev. 2/09