New Well CompletionHARNETT 7PARTMENT OF PUBLIC HEALTH PEA- `T
TO CONS _ _tUCT A DRINKING WATER SUPPLY WL --
PIN #: 0596-97-0689.000 Parcel #: 061506 0064 Application #: 16-5-38391 Subdivision:
Applicant Name: Michael Shean
Address: 711 Gardner RD
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Lot #: 4A
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 t /L Date
Grouting Inspection Wi essed Date _
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
Date: (rytV'1 Application #:"l�d'i`11
Applicant Name:
Address: �I(�tsr2ar•.a_/�/�
Directions to Site:
q- 241- / (o
WELL CERTIFICATE OF COMPLETION
Well Contractor: -LE-A/,�
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: P!uno ID Tag: Sampling Tap: Backflow Preventer: _
Sample Taken? ❑ Yes EJ" No Well Head properly sealed:
Remarks:
Authorized State Age G Date
See Attachment for competion sketch
Application #:16-5-38391 Applicant Nar, Michael Shean Subdivision: I 4: 4A
Well Construction Sketch
Well Completion Sketch
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WELL CONSTRUCTION RECORD
Thu farm inn W used for sinal. w mahiplowelld
1.ell Contractor Information:
LAra In/Jr
Wall Canvacter NWO
NC wall Convaaa Cmifiauioa 'umbar
rlswelk v�lt;na
Company Name
2. Well Construction Per mit d: lafi _✓ — s
u"tar/appiaablr.a0 panarlb 0.e. Ca Io' Srdre Vanwer. !^heriµa, rn.J
3. Well Use (check well use):
DAgnoultural OMunicipal/Public
DGcothermal(Noting/Cnnling Supply) WRoidenual Waco Supply (single)
Dlndvsnisveommocial ` acndcndal Waw Supply(shared)
DAquitbr Recharge
DOroursimbar Remediation
OAquifa Storage and Recovery
OSaliniry Barney
DAquifo Tot
OStonst"orDrainage
DExperimmud Technology
OSubsidence Control
00am larmal (Closed Loop)
OTmotr
4. Date Willis) Completed. -a —I k Well
5a. Well Location:
rn ichaeI SheaA
,PaOity/pwner Name fait", Ina(ifappliceale)
j 3a`7 aAll'gch Uu�A Ad Lon Nc Arrli`
Pb,eiacl Ad imc Cay, and Tap
}aYne+l—
sunly Pw<el Idmu6ruion No. (PIN)
5b. Latitude and Longitude in degreea/mmums/secoods or decimal degrees:
(Iftwll paid, ane lal/long a suffiolam)
35° /51 5-0L N ]f<° 4bf OS5 W
6. Is (arc) the we11(3). *ermanent or OTemporary
7. Is this repair to an existing well: DYu or o
JlAn a a wpoi,, fro avr Darn red eonrrr.urar aJ6rmaran a loin rho cemro ,lila
fir .rubs sal rvrrmrrL ,IClpn or On lar baa njrldn frim.
8. NumDo of welly oonatructed:
fo,wdnpkl Xcoap or lran.rprar avpply.erls UHL rya ria naps aanmacouw, yav can
rubnil une/brm. / 2r0y
9. Total well depth below land surface: r/3 e1 (A)
Fa,mwh pk well, der all depth, Ird(pawnr /emapr-JVOO'.and 2(4100)
10. Suite water level blow lop of coding: 15-
(R.)
(lwar few) n a60w 031.4;W . r-
11. Bmthole diameter: / (io,
12. Well construction method: M��r��rr
(ic auger, raay. wbi , direct 1 Wh, ere.)
R.
n. I R.
uw�a
ct��sa
22. Certification:
By ripping W/, fomr. I he -by
ruh 10A NCAC 02C.0100 or
appy.fab arena an, damp
23. Site diagram or additt
You may use the back of I
construction details. You li
_6.-j1�
Dye
Cei ) mmrrreadin aesraxr
lemrrvMan 6'mmsunis and rain.
to provide additional well aim details or well
mach additional Ingo if pecuniary.
24a. For AR Wells: Submi9'this form within 30 days of complction of well
comtmction to the following:
1617 Mail
24b. F,, loiter no Well
24a above, also subrim i
.... umcdo,In the folio.
Division of Water f
FOR WATER SUPPLY WELLS ONLY: 1636 Mail
13a. Yield (Spin) Method of tot:U JOl 24c. For WaterSumpo )ply 1I
Also submit one copy t
4 C LL, well construction to the
13b. Disinfection type: Amount eonsnueled.
oourcca, Information Processing Unit,
e Center, Raleigh, NC 276991617
Y: In addition to sending the form to the address In
of this form within 30 days of completion of well
Underground Injection Control Program,
mint, Raleigh, NC 27699-1636
form withln 30 days of completion of
hdalm department of the county where
Pg.OW1 Nor.Caolin.0"aronenlef Envir.a... and Nalcoal Reaovrus- Division of.,nerRaawea Ri;l*%JA4142013