New Well CompletionHARP r DEPARTMENT OF PUBLIC HEALTH 2MIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0674-34-2326.000 Parcel #: 040674 002101 Application #: 13-5-31908 Subdivision:
Applicant Name: Bobby Joe Elkins
Address: 773 Rawls Church RD Angier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: County Sewer
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
csa.
Authorized State Agen ��-� Date LY —11 — ( y
Grouting Inspection Witnessed Date
❑ 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
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 ❑ No Well Head properly sealed:
Remarks: VSrnr-'�
Authorized State A L Date
See Attachment for com etion sketch
1-7-15,
Application #:13-5-31908
Well
Well Completion Sketch
Applican ne: Bobby Joe Elkins Subdivision: _ Lot #: 1
Ile
E416
►6s a rd)
Jun, 1 2014g,12:18PMpNg&C9RD
'rine (Otto can bo used Lbr alogia a0` multiply wetle
1. Well Contmetorinfoorrmation.
til sti G . �' �r►r�
Well Contractor Narne
NC Well Contractor CcstiQcadonNumber
N.W. Poole Well & Pump Co.
Compegy Name
2. Well Construction Permit 9:
Lot oil applicable wall tnnarrucr/on parnttls ll.e. k4larm 0410, r -none, ars)
I Well Use (check well use):
6-- 61VOY
No A55; P 1
ElAgricultural ❑Municipal/public
QCeothermal (Heating/Cool,ne Supply) /tesidendal Water supply (single)
oledustrial/Commercial CResidential Watcr9u I shared)
PP Y
ter
❑Aquifer kecllarga
OAquifttr Storage and Recovery
OAquifer Teat
oExperimental Technology
Meothermal(Closed Loop)
00roundwater Remediation
o5alirlity Barrier
OStorruwater Drainage
OSubaidence Control
OTtacer
�v-vnw,u,r: rncaWtt 1�0011r1 1{.aC/Urrl ❑gther (girt under 921 Rem&&
4, Date Well(s) Completed:
S. Well Location;
�47tE
Foailety/0/�erNemO p / faoility10#(if applicable)
IVdh�v S G�Gf ti �.• �,��
Physical Addroe9, City, and Zip
111
Caupty
Parcel ldenti fie tioa No. (PIN)
Sb. Latitude and Longitude m degrees/mInutesilsecoods or decimal degrees:
(ifwoU fifield,3
v:to lat4ong is attf6oieat) ��.. cnutcaaoar
W
For latorpal Use ONLY:
6. Is (are) the well(a): Vermatlent or OTentporasy .. Sigoenue o Ceni6ed WeU Coonectrr
1}
7. Is this a repair to an existing well; ❑Xes or o
If Ihfs is a repofr, Jill our brown welt cmtao-gcilm leororalion ohd *lain the nature jibe
►epolr onds0` H2l rarnorkr Poffon 0, on the back of 0`h/s form.
g. Number of wells coustructedt '
Far mull/pie Injection or non-woler sadply welis ONLY wilt the Sam
conttfnctlon, you can
ubmit one form, �}
9. Total well depth below land surface: � 7`32 s' (�)
Tor nud/rple wells Jtdt 0tf depths (jd�irant (erampre 300' and 2®100')
10. Sta tic warer level below top of caslug. 3 U
If"'oter Laval /a obova coning, ase "a lam)
11, Borehole dlatoeter:
12, Well coustructlon taethod: reh,r
(i.e. sugar, rotary, rabic, direct push,
13.1' OR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
Lab. Disinfection type:
Aa- Amount: CPO
pate
y signing this form, I hereby eery Thor he wol/(s) W& (were) eonsrycred fir• accordance
with ISA NCAC 02C.0160 or ISA NCAC 02C.0200 Well Consfrtrerlon Standards and that o
copy of this 0`800111 has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details,: You may also attach additional pages if necessary,
74, Subinittal Instructions:
24a. Eff-AA,$'. M. Submit this form within 30 days of completion of well
eoastroction to the following;
Division of Water Quality, Information processing Unit,
1647 Mali Service Ceuteq Raleigh, NC 27699.1617
24b, r e : In addition to sending the form to the address in 24a
above, also submit a Dopy of this form Within 30 days of cotapletion of well
GOOtruction to the following:
Division of Water Quality, Underground injection Control Program,
1636 MaU Service Center, Raleigh, NC 27699.1436
24m Por . alar cuooly & .anfM.►...er min addition to sending the focal to
the Address(es) above, also submit one copy of this form within 30 days of
Where constructed,
completion of well construction to the county health department of the county
Form OW -1 North Carolias Departaacat of Envlrantucat aqd Nanual Resources — Division of Water Quality
Rovisedlso. 2013