New Well Authorization To ConstructW- TT DEPARTMENT OF PUBLIC HEALT! ;RMIT
TO � _ NSTRUCT A DRINKING WATER SUPPL. WELL
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$560 Parcel #: D F Z Application #y'11914 Subdivision: _ Lot #:
Applicant Name: �4a fdN
Address: Wy 1J4"_"O 4064 Al. C. z'7&t 2—
Type
Type of Facility Served by Well: SFD
Sewage System: �S �a
Permit Conditions: �o /a c�,e fa1QQ
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 J �� �b 26 / L
Grouting Inspection Wt teased 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
(deoth)
Casine
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
See Attachment for completion sketch
Date
Application #: Applicant Name Subdivision:
Well Construction Sketch
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Well Completion Sketch
Lot #:
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