New Well ConstructionHARNr -T DEPARTMENT OF PUBLIC HEALTH" 1MIT
TO 6k-~.STRUCT A DRINKING WATER SUPPL ,SELL
PIN 0589-29-7662.000 Parcel 07-0692-0163 Application 10-5-25146 Subdivision: Lot 1
Applicant Name: Darvll Robert
s
Address: 2466 NC 55W Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions: 100 foot off of Septic and Repair Areas
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 Agev4)_ Z,4(,,4 ~ Date q- /~'=ly
Grouting Inspection Witnessed Date
❑ Grouting self-certified by driller GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application Well Contractor:
Applicant Name:
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)
Casins
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: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks
Authorized State Agent Date
See Attachment for completion sketch
Application #:10-5-25146
Well Construction Sketch
Applican(,~ •ne: Daryll Roberts Subdivision: '-ot 1
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Well Completion Sketch