New Well CompletionHART T DEPARTMENT OF PUBLIC HEALTH RMIT
TO Ct—. STRUCT A DRINKING WATER SUPPLx v✓ELL
PIN #: 0625-62-1704.000 Parcel #: 05-0624-0016-06
Applicant Name: Michael & Elizabeth Smith
Address: 540 Farabow Dr
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Application #: 13-5-32493R Subdivision: Lot #: 5
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 Age Date '3
Grouting Inspection Wtnessed 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)
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: �j Backflow Preventer:
Sample Taken? es F-1 No Well Head properly sealed:
Remarks:
Authorized State Agent Date
See Attachment for comp on sketch
�r
Application #:13-5-32493R Applicar me: Michael & Elizabeth Smith Sub( :on: Lot #: 5
Well Completion Sketch
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Aug 2714 02:22p
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ESIDENTIAL WELL CONSTRUCTION RECORD /j,
Noah Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # / 2
1.WELLL C�O�NTRACTOR-
Weli C tractor(individual) Nametra�ctor(individual) Name
WWell Contractor Company NameCompany Name
STREET ADDRESS:
�1 1
City or lJown State Zip Code
Area code- Phone number
2 -WELL INFORMATEON: ,9 j
SITE WELL 1D# (if applicable) l/moi CrL 0 G
STATE WELL PERMIT#f (if appficable)�,y (sE,�, -(�- %7t? it • pdd
DWQ or OTHER P RFATfI(if applicable)
WELL USE: 41-1 ys
DATE DRILLEDy�-- j
TIME COMPLETED -3,009 r y
0
3 -WELL LOCATION:
CITY: I COUNTY 0A
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Cotte)
TOPOGRAPHIC I LAND SETTING: CR` �f �Cf}�/:' �(>j. .3 IL
LATITUDE _` '} 7 70 `T May be in degrees,
LONGITUDE --% J -c —fie �� minuus seconds ar
i in a decimal format
Latitude/ longitude source.,(��
(location of well must be shown an a USGS topo map and
attached to this form if not using GPS)
WELL OWNER:
OWNER'S NAME
STREET ADORE'
` 7A %'
+, ry oral own State Zip Code
(33o - ;I,� t5 C/ 6
Area code - R -one number
WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? No
c. WATER LEVEL — FT,
(Use "+° if Above Top of Casing) -{`'
d. TOP OF CASING IS % FT. Above Land Surface
*Top of casing terminated auor below land surface may require a
variance in accordance with 15A NCAC 2C .D118.
e. YIELD f9pm): 30 METHOD OF TEST
Submit the original to the Division of Water Quality within 30 d
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone Na. (919)
L DISINFECTION: Type 11 LI -4 Amount
g. WATER ZONES (depth):
From
'R -2 U To A2
From
To
From
To
From
To
From
To
From
To
6. CASING:
Thickness✓
Depth
Diameter Weight
From G
To ] S
y�Material
Ft. _
From
To
FL
From
To
Ft.
% GROUT:
From 0
Depth
To as-
Mat�na%� Pflethod
Ft. f A -f (e fw it ✓" '�'�
From
To
Ft.
From
To
FL
8. SCREEN:
Depth
DiarrWer Slot Size Material
From
To
Ft in. in
From
To
Ft in. in.
From
To
Ft in. in,
9. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
From
To
Ft.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C LL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOZ1DFNP DHEWELLOWNER.
, rzt
SI ERTIFIED WEL CONTRACTOR DATE
% REO� lrti � ry
PRIN; D NAME OF PMSON CONSTRUCTING THE WELL
ays. Attn: Information Mgt, Form GWAb
733-7015 ext 568, Rev, 7/05