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Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT TO CONSTRUCT A DRINKING WATER SUPPLY WELL PIN 0680-71-6093.000 Parcel 07-0680-0025-02 Application 10-5-24925 Applicant Name: Randall Max Gregory Address: 1350 Fleming RD Type of Facility Served by Well: SFD Sewage System: Permit Conditions: 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 Date Grouting Inspection Witnessed/ Date 9. zs =iy ❑ Grouting self-certified by drilwr GW-1 provided'? ❑ Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: 9-9-10 Application #:10-5-24925 Well Contractor: Roger Jackson Applicant Name: Randall Max Greer Address: 1350 Fleming RD COATS N.C. 27521 Directions to Site: Use of Well: SFD Date Drilled: 8-25-10 Total Depth: 240 Replacement Well? E Yes ❑ No Static Water Level: 22 Top of Casing is 12 in. above surface. Yield: 100+ gpm at Disinfection: Type HTH Amount 160Z Water Zone (depth) Casing From 22 To 240 Grout From 0 To 80 From 0 To 25 From To Diameter: 6.5 Material: PVC Thickness: Material: CONCRETE Method: POUR From To From To From To Diameter: Material: Thickness: Material: Method: From To From To Diameter: Material: Thickness: Material: Method: Inspector: JEM On Hold Date: Release Date: Remarks: Well Head Information Casing Height: 12 (above finished grade) Access Port: YES Vent Stack: YES Well ID Tag: YES Pump ID Tag: YES Sampling Tap: YES Backflow Preventer: YES Sample Taken? ❑ Yes ® No Well Head properly sealed: YES Remarks: Authorized State Ager ~ ,~y / ~ Date 9-4 -/a See Attachment for completion sketch Application Applicant Name: Subdivision: Lot Well Construction Sketch . a.0 My rm u :Q *Aua 7we WE" COWRACTOR. :31 vidlidd!341 JACKSON WELL RESIl)ENTIAJ r i cp VMQN txr Qw Noah Gunlm Ae_parftwat of Envuunwm t std Nlwu Rmurs- rhivuwD of Wab w Qum," WELL CONTRACTOR CERMCA'Y'I0N # 2179 r W. Jackson WeM Cw~tracaor game Wcrn Weft ComDanv (~arr~ppnyr Name STREET AabAMS 5860 McDounim Rpm f..If' North Caroline 27'x!6 CIY W TMM 5tsle rip coda number 2- Wt"INIVANAftft WE Wt3L to STATE W&L F~tArfrip Dwo or OINt R P AMFr K$f app*wbiel Wt'.LL + (Chwok IWproahle A Mw" wawr SuPIPtY~ ''r DATE aWLiac► TIM AMa PM* z. WELL L 0-0- A~Q~ . C(tY: t~+~t Nerns Mie~birapp,nrq y, Lat No., P~eroo, zip Cod' r TO" LAM SErnN%. Elvalley ORed op** ta+ 0 C7NkNt r LATFTu* 3„ Rr may be in *s LONOMME 2 !n Mbaft "0006 s da~anl Parn►etj lA6UWWb*'t9* aoMM DOW 77TOPOgraphk RX09" of VON maw be ehvwn v* km Now uA"v Q067 s Us" bpo R" +hd amaw >tt 4. WELL. OIL OWE NAAW 01~ U A°"k or Tin 94cae Zip Code coda. 13 1, 3 Amu Thom number & WELL UWAPAk TOTAL, pL~,pTy;,_„- r v DO" "MA MOMACE t'.XtBTtMp WUL? YESO NO a WATER LEM 8e dvw Tap at Cfthpr ~ - -T. if move Top of 04*0 d. TOP OF CAB OW IS ue FT. Above Land SurN"' *Top of Mfna agmllrsa~wd ahbr polcw kw wrtew may require a va imce to aawrawft I t►16A NCAC 20 .011$. a. Yww (VPO* _ ~ D16tNFEC'~'tq~ OF TEST- - 7" fat 10 a LNyblorr+ of W'01 tr Qu10111Y WMM 30 days. Ann: Information Mgt., - R&%kk NC Z78A8.18l7 Pty No. (E19) 783.7A1lf, ext W& p. WATER TONES (depth): rom _ Tq _ From T G2._To,- From Ti Fmm._._..... To FMm___ T. a CASW : Thkknow FmaL -OD ra7 TO r, - wolgM fiom Ta 0 Er Fmm- To PAGE 02/02 7' diROUr., Dept MawrtAi To--~! FmniL_ To F"R -r-L-M. FMM Tv Ft 4• GAVEL PACK: Depth Size Ft, . FKh______To Fry,- 74-~ Ft- Sias size in. Ma*Aw 10. ©RILLWO LOG FrcxtT To Formed ne~rfPllDn U 11. REMARtC'$: 100 wEU Va~r 7ktS wELL wNsooNSTrUjC MwACpp WOW REpogD w s MMN Poovw m~►+S w~ OW# THAT A CO" OF T)" kE-0 c tEa ELL CONTtgacTOA ~ v DATE . RagorW Jv&r4r- n PAIN I W RAW OF PERSON Z*gTRVCTttJCi Tt~' WM Fwq CAW-1a