New Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-37737
Applicant Name: Jonathan Powell
Address: 1019 Valley Rd. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in Well Area
Subdivision: Lot #:
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 Agent[&,..0 .�_ ✓� .moo..,, C �� Date / G /20( c
Grouting Inspection Witnessed / Date
❑ Grouting self -certified by driller GW -1 provided'? 0 Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address: _
Directions to Site:
Use of Well: _
Static Water Level:
Disinfection: Type _
Water Zone (depth)
From _ To
From To _
From To
Inspector:
Remarks:
Date Drilled: Total Depth: Replacement Well? ❑ Yes ❑ No
Top of Casing is _ in. above surface. Yield: _ gpm at ft.
Amount
Casing
From _ To _
Diameter: Material: Thickness:
From _ To _
Diameter: Material: Thickness:
From To _
Diameter: Material: Thickness:
On Hold Date: Release Date:
Grout
From 0 To
Material: Method: _
From To
Material: Method: _
From To _
Material: Method:
Well Head Information
Casin ghHei ht: _1_�
g / (above finished grade) Access Pon: � Vent Stack: r_
Well ID Tag: Pump ID Tag: Sampling Tap Backflow Preventer:
Sample Taken? D"Ves ❑ No Well Head properly sealed:
Remarks:
Authorized State Agee Date q-74-14
See Attachment for comp) on sketch
Application #: 15-5-37737 Applicant Name: Jonathan Powell Subdivision: Lot #:
Well Construction Sketch
Existing
Well
Septic
Tank O
House
100 ft. �\
rWeII
Driveway
Well Completion Sketch
WELL CONSTRUCTION RECORD
This farm eau le umd fors %le ormukiplewells
1. Wen Contractor Wormation:
Roger W. Jackson
Well Cm. tar Name
2179-A
NC Well COdeelm Cmttfimti uNomba
Jackson Well Company
Company N®e
2 Wen Construction permit#:
Litt aU applicabl, mfi peon& (Le Ceram,. Stat, pmioom, byecfimy em)
3. Wen Use (chedcweff nae):
nAgiculhml OMrmicTal/Public
OGeothermah(Beahng/Cmling Supply) .'%mud Waren Supply (.me.)
01ndtstn"Commarmal OResdamal Water Supply (shared)
OAquifer Recharge
OGmundwater Remediation
OAqud'er Storage and Recovery
OSahnityBamer
OAquifer Test
CStorurwater Drainage
Experimental Technology
OSubndence Control
110eothermai (Closed Loup)
OTracer
4. Hate wdl(s)Compid<d: X744—/ Weti ID#
Ser. Well Loention: - — - --
Facility/Ow�Name )try ( aPpLcebk)
Fac" ID# if
/o/
Physw"ddas, City, and/T
rhea TT
Conary Parcel Idvrifration No. (PIN)
SIL latitude and Lonpurde in degrecslhdmdWs¢eonds or decimal degrees:
Cif Wen field, on: Wangs summed)
34 -'0/ N 7f--dS6 X73 W
G TS (ase)fhewdl(a>: wa aOetma t or OTemPorW7
7. Is this a repair to an existingweil: fWes or ONo
lfdds is a reprdI f& outbmau wv0mnmtrbon gy&,naewr anderplab, as wane oftlu
mPav`w rler#21 remwkrsvaaw, or o, da back o/feosfonn
S. Number ofwells mkstrueted• /
F m,dApla 6gecCan ornm-wrt. pply»aQr ONLPwid, Bce aawecoeabaerion.}w cmc
svbautmwfona
9. Total well
depth below laud,m, (R)
Faraad(ipk avQr&t aUdTPd+r ifd,ffrraa (ermny]¢-3(t$200'and23(�7700)
10. Staticwatelem below topofmang: / (R)
7fwaNr harsh is above caroig are "+"
11. Borehole diameter.4/ Com)// f
12 WeB construction method: 1l f r`' /J! 6 N t/
(i e, aaax, tay. Babb, daeap,ah. oe)
Farbt wUse ONLY:
/S .b 3 773 %
FROM
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DESCR�itON
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DW1HIYa r KMMS MATEaIAL
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i0 DIAMxrra, I RIA = I Td,,m, s MATERIAL'
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MAT'F.RrAL EMp C METRODAAMOIINT
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it.
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PROM
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MArSRIAL FLIPLACEREM BIETHOD
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DFBCR (Xf mbr ham aoR/m},~-
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sL
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Bl' .vigrmg dein form "u -by -'Vy #- da wea(s) was (were) cmutrnchd m aceordwwc
ai& I34NCAC 02C.0100 or ISA NCAC OK.0200 WeR Cwcmacaw, Moaid dr andthat a
copy ofddr recardhasbem provided!, Dee sell owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
consbuctimdetails. You may also aM=h additional pages ffnececsary.
SUBMITTAL INSTUCnONS
242. For An Wells: Submit this form vn" 30 days of completion of well
construction to thefoll—Ing:
Division of Water Remurcrs, biformation processing Unit,
1617 Mail Service Centey Raleigh, NC 27699-1617
24h For Iuiection Wells ONLY: In addition to sending the form to the address m
24a above, also, submit a copy of this farm within 30 days of completion of well
construction to the following-
Division,
ollowing
Division of Water Rem—es, Undeagrod Injection Comlmh program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, R2104914 NC 27699L-1636
13, Yid (am) /0 Method oftesk / / #0 24e. For Water Supply & Inierean Webs:
�-y� Aho submit me eoPY of this fon withm 30 days ofcomplotion of
136. Disinfection type: At Tl Amomrk dwell Construction to Wme only health deparmtent of the cmmty where
constructed.
Form GW -I Nonh Carolhu
DeparDoed ofFnvvanmed and Netuwt Resoiao-s- I):vision ofWaterliemmces Revsed A,guu 2013