WELL COMPLETIONHARNE' DEPARTMENT OF PUBLIC HEALTH PI ZIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1610-16-3520 Parcel #: 071610 0054 10 Application #: 14-5-34160 Subdivision:
Applicant Name: Larry K Baker
Address: 555 Festus RD Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: Ultra Shallow Conventional
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 Agnt Date ;— 2-4 —) c{
Grouting Inspection Witieed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: JZ -114 Application #: Well Contractor:
Applicant Name: i✓u
_
/3�
Address: 1
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 j
Casing Height: 11¢ (above finished grade) Access Port: Vent Stack:
Well ID Tag: / Pum ID Tag: � Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes Q No Well Head properly sealed:
Remarks:
Authorized State Age "J�� Date j i -10 _ l
See Attachment for comps ion sketch
Application #:14-5-34160 Applicant N ;: Larry K Baker Subdivision: t#: 2
Well Construction Sketch
Well Completion Sketch
v�-
7Z
I►r�ji, 11�O nI7
L
t
i
v
lot
10/30/2014 05:16 6410248
Ir
WELL C!2NSTRUCTION RECORD
This form can be used for single or mutiple wells
1. Well Contractor Information:
Chauncey Leggett
Well Contractor Name
2269-A
k., Welt Contractor Certification Number
Lake Volley Well Co., Inc
Company Nam- e
For Internal Use ONLY:
ME'"O'EMI
FROM , TO DESC91WrION
........... 130ft.; 300 ft.
..... . .. .......... . . ..... ....... .
2, Well Construction Permit 14-5-3411,60
hist all applicabla, well awarurtion purinlits ft (.'aunty, &010, porianug, 01C.
3. Well U$c:
PAGE 01
:FROM
TO i
DIAMETER I
THICKNESS MATERIAL
0 R
143 ft- 6.25
SDR21 PVC plastic
FROM f 0 MATERIAL 80,
ft,
ft, 2ft,_ ChnccetP_._...
C,c�utJlxg Through
ammmokmn.
ft.
.6.0. pentimite slur
.1remip..pte,
FROM
.............
TODIAMETER
..... ..... .. .........
MATERIAL
ft
FROM rO MATERIAL EMPLACEMENT METHOD & AMOUNT
... . . ......
4. Dole Wells) Completed. 10/29/2014 Well IQ#
..........
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential
. .. .........
............... .......
.... ...
"M, 1111MOU N
MEMO 91TWHOD MOUNT
NEWELACEMMERT
FROM f 0 MATERIAL 80,
ft, 2ft,_ ChnccetP_._...
C,c�utJlxg Through
ft.
.6.0. pentimite slur
.1remip..pte,
FROM rO MATERIAL EMPLACEMENT METHOD & AMOUNT
.... . ...... L.
4. Dole Wells) Completed. 10/29/2014 Well IQ#
..........
!ia. Well Location.,
111),
Lai ull upplicaNe well conmructfon perlmors (le ('aunty. ,Stare, Vartance, ('it-.
r!?TTT"�"
grain size, etc)
Larry K. Baker
1 1. ..
l"Raility0wner Name Facility 11) (if upplitabla)
.. -.1 ....."." I . ..... ...
70 ft.; 85 ft.', Orange Clay
555 Festus Road Costs 27621 Lot
1-1......... 1 . ............ ......
65 ft, 126 ft, i Orange Shale
Physical Address, City, and Zip
125 it. 130 ft,! Gray Shale
Harnett 071610005410
130 ft. 300 ft.: Gray Granite
County Pfifftl IduntifloAtiotl No. (111N)
tt ft,
Sb, Latitude and Longitude degrees/minutes/seconds or decimal degrees:
... . .... .............. . .... ... .... ...
t.
(11' well field, otic latlong is sufficient.)
35.415557 N -78.627415 W
. . ....
6. Is (art) the well(a): Permanent
..•.............. .
7. Is this a repair to to existing well: No
22. Ceril
C"
C
c tion -
10/29/2014
�co
lflky is a ropair'.1111 out known wall crinsmuetion 1A.1br4tallon and explain the norum of
.. ........... . .
Signal 0 i 01 CoIlleaclor Date
rulnor wTajvr,: 21 mmarkv.vaction or fin the back qffh1x.1brm.
fi,yvigiping fbix,form. I herthy cart!& that the welf(s) was (were) cvrvru(.(04 in accordance
with 15A N(.*A(.'()2(:. 0/00 or ISANCAC 02C,0200 Wolf Canytructionstandayt& and that a
8. Number of wells constructed: 1
C.-upy re'lky record has been Provided to the W011 owner.
/,or 11174hiplo inJrclinn or Pion-Witer wefix (Y)VIY with thesaffle construction, you can
23. Site diagram or additional well details-
vuhnfil oful'thral.
You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
9. Total well depth below land surface: 300 (ft.)
Por toullfole welk fin all depth.v ita(ffctruppi (jvx(rmp1q- 3@ 200' and (i; 100)
8t )MITTAL INSTRUCTIM
24s, for All Wells: Submit this form. within 30 days of completion of well
10. Static water level below top of casing: 20
construction to the following:
lf'water lelmet is above casing, wo
Division of Water Quality, Information Procession k) nit,
6 (in.)
IL Borehole diameter: ....6_.._.
1617 Mail Service Center, Raleigh, NC 276"-1617
12. Well construction method: Rotary air
24b. For lialgetlen Weill.- in addition to sending the form to the address in 24a
(i.o. auger, rotary, cable. direct push, etc.)
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY:
Uivision of Water Quality, Undergroun injection Control Program,
1636 Mail Service Center, Ralelgh, NC 27699-1636
13a. Yield (gpm): 5 Method of test: Air
oupply InigetipAWells- In addtion to sending the form to
24c, For WaterS
the tiddress(o) above, also submit one copy of this farm within 30 days of
13b. Disinfection type: HTH Amount: 15
completion of well construction to the county health department of the county
where constructed.
Funn OW- I Nonh carolina Department of Environtricni and Natural Resources - Division of Water quality Revised Jan 2013