New Well Completion PermitHART .'T DEPARTMENT OF PUBLIC HEALTH RMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0681 80 8936.000 Parcel #: 07 0681 0001 06 Application #: 13 -5 -32459 Subdivision:
Applicant Name: Brandon & Victoria Butler
Address: 1308 Old Stage Rd Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 1
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 Ag6d Date
Grouting Inspection Witnessed Date
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: i z-2,-Jy 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)
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:
On Hold 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 Ag Date
See Attachment for completion sketch
Application #:13 -5 -32459 Applica' ame: Brandon & Victoria Butler Sub!, ;ion: Lot #: 1
Well Construction Sketch
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WELL CtHMRACTM CMTMCATM)l I 2f 19
9. WATER Z (d"):
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FRMI T9 Fmm
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d CA$INQ; Thief/
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Fmm_ To_.,_, ft,
7. GROW: Depth
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From_, To_
FrortL,_ To_
L SCREFd1: Depth
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Frog — To_
Fmm _ To_
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9. M WORAYEL PACK,
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Front.. To Ft.,_ _
Fmm To ._._ A-
FnouTt_ To, Ft.
TG, DRILLING LOG
From TO A m alion DwAptlon
Li. REMARKS:
1 IXJ #MEA'Y ;,EATIFY TWIT ?N!$ WELL WAS OD?l$7iUlCTffi W ACCORWNM
!Ft W6#4 SA WRU 0914 UCTgH STANPMOS. AND THAT A COPY OF ThIS
RKOM WAS MMN PROW Det TO -n-M WELL OWNER.
SIOINA E OFCEOFIED WELL GOVT% Mp DA
IRMsr W. Jackson _
PFaINTED NAI'AEOF PERSON Co mST'RtlC ofeTHE WELL
&Jbmtt M�{e�� � � kMI to #w p got atW Quality wMn 8Q days. Ann: titormation tAgt., �_v
1617 gandow Ya - o.w- ..d. eu. wvwwa -w w{.._ -_ "......a .u-- . r« %„