New Well Completion PermitHAR. —TT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0692-58-0920.000 Parcel #: 040692 0039 Application #: 15-5-36010 Subdivision:
Applicant Name: Paul Rian Dupree & Danielle Dupree
Address: PO Box 1612 Angier N.C. 27501
Type of Facility Served by Well: MOD
Sewage System: Pump to 25% Reduction System
Permit Conditions:
Lot #: 3
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 l- Date S ® u
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: V Application #: OT --57- o�, Well Contractor:
Applicant Name:a v) �up
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: t2 (above finished grade) Access Port: Vent Stack:
Well ID Tag: 7� Pum ID Tag: Sampling Tap: Backflow Preventers
Sample Taken? ❑ Yes �No Well Head properly sealed:
Remarks:
Authorized State Agent ars �' Date t -Ll - 15'
See Attachment for completi n sketch
Application #:15-5-36010 Applicai. _game: Paul Rian Dupree & Danielle Dupree Subdivision: Lot #: 3
Well Construction Sketch
Well Completion Sketch
Z'
J
�n.Q17
1='i -b
R,E1CONSTRUCTIQ , C.'m
'fins firrm call, ho used 16r singld urmllliipl : %[0114
1, Wull Cl trucku►' ShYot•t riot[: �
441411 Cont-adarMasxe
xct C,3,3u'nutw• d,iitic�tiuu �tanlz
cielk
Curuparnl'� nJ
2. Well cumtrutttonPeratltt
Llat ell Rppucablo -AvIl parmirs (t,a. coffin «. SmIe. I --u'fame,1+11ccNas, old.l
3, Well CAP (check Well use):
OAgdCliltitiml
Ll" 1Efeotl igNtRl (HratingtCooling Su1J31y}
aladustrial/commeraiat
CAquif�i-RdtImm,ge
C3Aquitbe Sttu'nga rind Ruvuvery
E]Aquifer Test
Cil;wilerhimitai Twhiurtugy
Odcatharmal (Closed Loop)
4, Dam wull(s) completed:
74ipallPttl'3lia
tinl WatCf Supple• (aiuglu)
❑Re,ridentiul water supply (11 weed)
0 (ltlnu[d%vIlWr Rmnu;di utim
03afistitt' Ilarritu-
Q ti miw'ater Drainage
CISubsldcut:e agavol
ElTromer
13001ar (eNolAin lnnde[- 421 I
Imo
Ag, iL�oatt
d1J1 �
FdefflivOwaeri`oom laeilin IDE, (it'epplleaf3ly)
Pilyaicel s 4drdslh City, 1ul4trip �
Cuw3ty ptlrnalltldntitldatfua ku.ON)
3b, Latitude 3md Longitude In du rueshrrinuieslsaeuntis or dedmil degrees:
(It•Kutl 11RId, olid laviong is sufflcixat)
Wt. ,
6, Is (are) the well(s): Crminent or tMinpulary
7. Is this a repair to an existing well: ❑Yea or [ f
if this m a rspam fill aw k+rtnn well eotrstructfo„ tlilbrmerftorr Rxd > xpia3o fNr• mxxrt: u1 iho
rrpRir ru[dor hI ! t>"+N3tnls ieatttut or err
01116, 1j7tdr rrn.
S. Number of w0h t'nnstrueted: _
FrN rNrtltlt)lu byeettan or man -:,'.our ippP4,11,,'111(JNkj, )rlfh flh3 amua exsastrwrtldn, )t u c,ot
.snbn,fr a+re fa'rrr.
9, Total well depth below land sarttree:
Har Igglopre wells 11.1 etch d pillf (j'efiptblwilt (stt4,N+p1c- 3� 71N1' eo,d 2�71GG j
1tt. $tpHu tYitet' hovel belovt' cup of chslhg: 2.0
If. ware+• laeal is 41hom caw ,w. 11.m) N, •'
11. Borehole diamettr:
13, 1i'dl! aenstrttcttan method« lCII
(i•d. aagar_ rulmy cai3lu, dined pusli, etcj--
Av 1111mial Use UXL'y:
22. C tion;
9l2nrtQrrw o 'era dd 14',311 CWiLaatur lint
,rip3rf,tq it+tr- 'm ! lnr3wba• um-rtfj• rho[ rho xaA(q) ut7; 61-4m) Gri113iJ•fldm'i f!1 RCC*ftkHkn
uFrh 13rt ,bCrtC t1X .4144 ar l� l AC 47C.0.24U ft atl CuuatrualNtrr .iYrNrrlw rh' lu3+l rhnr It
copy r f'MIN rmcra[t uft bgvtlINYAI,*d ra the well ot-ml.,
23, Bite diagrin[ ar edditional lYeil dotalls:
Yntt may use the back Of thus page to pmvid3s additlrmal atoll site details or %I -all
eonst[uction datails. You tnay also attach additiandl pages if n etiro,ty
SURAMTA,L INSTUCTItyN&
24a• E4C AH M11 : Sttb[ltit Aria bean n�thin 30 degs or completion of IN -011
cunstiufiun to the fullatiing:
Division of Water Resonrrxs, Information Protesting Unit,
1617 Mata Service Center, Ytalelgh, NC 276119.1617
24b. Fitt F1tiy,�tjplj Wells ONLY, in addition to sending the Yarm to the address in
24nabm+e, also submit n copy of thus form %eitilin 30 drys of 3;n3ttplation of nroll
consttuctiun to tllC ml04tit[g:
Divisiun of WaterR"Ources, Undergruund Injection Control Program,
FOR WATER SUPPLY
�WELLS ONLY; �--,{ 1.634 Mail Seraice+ Center, RJAWigh, NC 2709.1636
13a, yield (Spm) - _ !r 01D Mittliod of test-_1�T�� " Nc. FLr Witat' iyprmh 5�, ectiun W`ils;
Also submit unit a qny of thrix timrn within 31) days of completion of
13b. Ditintitctiun type: 4v Amuutd: wolf CwlslrttCtitln ttr tiler uounty itcolth dupntunent of ilia t il►nty et}nemv
ounytnu:Ged.
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TOO In 'IIMA 1I„LaA0q Q260> N2Z XV3 6C:$T LOOZ/6Z/60