New Well CompletionHARNVTT DEPARTMENT OF PUBLIC HEALTH PVRMIT
TO ( iSTRUCT A DRINKING WATER SUPPL /ELL
PIN #: 1518-77-8254.000 Parcel #: 02 1518 0011 11 Application #: 16-5-38224 Subdivision: _ Lot #: 12
Applicant Name: Betty Vollmer/ Dana Mcleod
Address:
Type of Facility Served by Well: DWMH
Sewage System: 25% Reduction
Permit Conditions:
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 A Date
Gr ting Inspection W ssed Date
[Grouting self -certified by driller GW -1 provided? Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: ,S -31^)(e Application #: 16.5' ell Contractor: L&02(JS((P�j2tY
ApplicantName:
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
(deothl
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 finJJJ''shed grade)/ Access Port: dent Stack:
Well ID Tag. PID Tag: Sampling Tap: / Backflow Preventers
Sample Taken? ❑ Yes No Well Head properly sealed: •_/
Remarks:
Authorized StateAgenLfY/&--a%sate 5 -"31—I( -
See Attachment for compVlon sketch
Application #:16-5-38224 Applican+ "ame: Betty Vollmer/ Dana Mcleod Subd' '-,ion: Lot #: 12
Well Construction Sketch
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i.JuI rs
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Well Comnletion Sketch
WELL CONSTRUCTION RECORD
Thiu him oen d vied for einple or mnluPl. wvlh
I. Well Coatuttor Information
Lav vi -6rd
Sr
W.t C... Nem
OSJiniry Bartter
[)Aquila Tot
ag&3-Pr
OExpetimental Technology
NC WeII Conu.ctor Ceniflutyy^^ NumMr
OGeothermJ (Closed Loop)
Inlil\��ords Wel\
1�ri11;�4
Company Nun-
a ss i
2. woll Construttion Pamst %:
Un all alp/iaohb osll prrnar p r. ('nwrry. lMn. Vorhm.e. !n/ecnm, <rea
3. Well Use (check well use).
DAgrieultuml OMunieipal/Public
OGeichimal(HutinglCwling Supply) *a,idemial Water Supply (single)
Olnduatdd/Commerctal OResidennal Water Supply (shared)
DAquifa Rahurgc
00mundwatcr Rcmcdinion
OAquifa Storage and Recovery
OSJiniry Bartter
[)Aquila Tot
OStor rw W Dr sWc
OExpetimental Technology
OSubsidenc<Connol
OGeothermJ (Closed Loop)
[)Tracer
4. Date Well(,) Completed:.r�. /o-lG Well 1D%
5a. well Location!
Dano m G160d
FwibJy*.rer N.ma Fuilit 104(ifypplic,blc)
SR 190�5 a�irgru w+Q
Phyncal AddNlf. On,rod 21P f.Z- a
BrArne-H— Loft ra
County Pawl Identi6euion N. (PIN)
51b. Latitude end Longitude in degraNminutesrseconds or decimal degrees:
(dwall Edd, mu WWI 10 e-15 ... 1)
350 miller N -790 3ro•a�l W
6. Is (art) the well(a): �Permancut or OTcmporary
7. Is this.repair to an existing well: [)Yes or **
6,Ao u a npvlr, flf vi, bwvn well eparrmenan rnJarmorlon aM espfam rhe names n/rhe
repair vdsr Q, ren vki rcclun or end. eacx off ufir
g. Number ofwells constructed;
For muhlphvr clJ.err mxtmarer nippy vers ONLY wlrh the rune wrvnveBan yxur can
nMnn we fwm.
9. Total wall depth below (and surface.
For maftfph well, fl,r.11 dephv 3@V60'.nd }(d 1001
10. Static water level below tap ofrasing:
/fwmerlewl b aaox rushy, um "."
11, Borehole diameter: 1 Mad
„
12. Well construction method: / ad rD to r
(i., supr, rotwY. ceblq dirtm Push, etc)
Intend
®■.
ff.T�d7�f•31C1I�7���d•��r'�
�ItaL7��IiYi� 19/ r,
DA
22. Certification: s
Sigwwe afC dWoll Con, Pum
By riyning rMs farm, l hrrch' w IMI rM wall(,) was (wc ) conruvaud In arcoldsrar
rah IIA N('Af 01('.0100 err /1 A[' rrS('.0100 Well CvrWrw:lhm $IadaNr aM rMI v
c'uPY a/Thin rottmr/,a, Mew proq lu the null weer.
23. Site diagram or additionj ) well details:
You may use the back of thil page to provide additional wall site details or wall
construction details. You mn kiw atuch additia l pages ifneeessary.
24a. For All WcO,: Subm� this form within 30 day, of completion of well
construction to the following:
Division of
24bsbr lviecritn Wdi•OI
24s above, also submit a CO
construction to the following:
Drvis,On of water Rest
FOR WATER SUPPLY WELLS ONLY: 1636 Mail
�n 14c. For Water Supply,
13a. Yield (gpm) Method of test; Also silbrail one copy i
Iib. Disinfection type. s '� t Amourtt; 1 1 w'GI conatructiw w me
constructed.
esources, Information Processing Unit,
e Center, Raleigh, NC 27599.1617
Y: In addition to sending the them to the address in
of Ihis farm within 30 days of completion of .11
Underground Injection Control Program,
:iter, Raleigh, NC 27699-1636
Drm within 30 days of completion of
health doparnnent of the county where
Vona CWd North Cwogn, Delunm.m of Pn.irenmem.0 Nuunl Resource- Di Mini of t,.r Ro.umw Retied Auaue13013