New Well CompletionHARNET— 1EPARTMENT OF PUBLIC HEALTH PE' -IT
TO CON, _ RUCT A DRINKING WATER SUPPLY W �_L
PIN #: 0596-97-4107.000 Parcel #: 061506 0066 02 Application #: 16-5-38364 Subdivision: _ Lot #: 5
Applicant Name: Signature Home Builders
Address:
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
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 /I
Authorized State A r4a.)/L�y Date /6
Grouting Inspection Wi nessed Date
❑ Grouting self -certified by driller GW -I provided? E] Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
J4 -s
Date: 11"9'111 Application #: 50V Well Contractor:
Applicant Name: bfrti"'
Address: a/v 1-� GA' /IBJ
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
(death)
Casin¢
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 Informa ' n
Casing Height: (above finished grade) Access Port: / Vent Stack: _
Well ID Tag: P�u ID Tag: � Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes U/ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment fo
Application #:16-5-38364 Applicant Nz - Signature Home Builders Subdivision: _ Lot #: 5
Well Construction Sketch
Well Completion Sketch
GT'
n 3 s-}
�c
52 031� A4,oce-4loxb
WELL CON STRUCTIONRECORO FalnmdVteCWY:
This form ma be void for simple m multiple visit.
1. Wall Contractor information:
LPr/NI W ml4:ZItd ay, Ef,
T
Wall Cannapwr w. �h�NC Will Cooewm Cmi6muon Numb,
T
Wel nrt Illnf a",RCompeny Nam.
_in
2. Well Com ruction Permit M; (° al .� o J r0 T A.
Wl Ynapolimhk wllPmej p., rosary, -Slow, Yneras,l [nw, fta.)
n. n.
3. Well Use (rbvck well vse);
DAgliculNral
gY .ripninp wNla furor, I Aneay
CGeothermal (Haling)COoling Supply)
�JMimicipal/Public
yylesidential Water Supply (single)
Olndustdemia
al/Comm)
6Rasidcntiat Water Supply (shared)
Ditrigadoo
Non -Water Suooiv Well:
23. Site diagram OY additions
DAquifet Recharge
CAgsufer Sumige and RrtA,.ary
CAquifer Test
CExpenmeeal Technology
00e0the e,61(Closed Loop)
4. Dale Well(s) Completed;
COmundwatar Romediation
DSOlinky Barrier
CStorm.wmr Drainage
CSub3idence Control
CTacv
A i R
5.. Well Location: ) L 5' Ak-furp HofS+P 3ull�rS P.miny/Oswers, F.cili" ION ofpplivshw
Ph sled Address, Coy, and Zip
Ph
D59/o-97-Y/el-°
Cressy PYrvel leamiifie[mn No. (PIN)
5b. Latitude and Longitude in degreesrminutea/eecoods or decimal degrees: 22, Certification:
(ifwell field .. IWlong is of isitsu)
35° /9,V63 N 99° �0.01�f W �.
Sipndwe oI C
6. Is well(a).'Permannt w OTemporary
gY .ripninp wNla furor, I Aneay
wwM /JA NCAC a)C.nlnO Yt 1JA
7, Is this repair l0 an emitting well: DYes or o
myy jtaix rocrud Ave sawn pwvkl
�l
UMIx YYs, Isi. [af/IYIX IA[gelY!(Iflll[
all
rofrir YMkr Y)/rvnmrtr osmium or en who dY �Yfrhiafrrm.
'k.VWgm or. wrrrM'(Ioflivrp
23. Site diagram OY additions
You m.y use the back of this
A. Number of wells wnsvucted:
construction details. You may
/'ill mYkl(d[ lXf`G'l1ygW KKlq-MYIILI )Ypa/y wllY °lrf.y W/M /A[ YMY CaIYIrYCIfM jYIV LVl1
rvbnw lore fgmr. 'f� 1y/
SUBMITTAL INSTUCTIOD
9. Iotal wail depth below land surface: "' 1 (R,)
24a. For All Wells: Submit
PotmYlnyk
eonsmimion to the following:
10. Statte water level below top ofeasing: / (ft.)
Division of Water
(fwgs[r k.1 k slow ammg, so, ",
1617 Mail Servi
11. Borehole diameter: [+ (in.)
246. For lniection Wells ONl
dyl
12. Well eonstructionmethod: MUel ro44rf/
24aabovc, also submit a cop,
eonswcuoe to the following:
Ilea svgs, rovey, cask, dwp push, No.)
Division ofwarar Ruom
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Seevi
Yield ' U jj f,[Ht� 1/Ids
24c. For Water Streets & Init
131. (gym) Method ofteat'.
fy�� 7- /—�—
Also submit One copy Of this
13b. Disinfection type: Amount: '1-4 4
.11 Lonavucua to the wunl
—all!--
constructed,
n
I 9� /-16
IitY
,As, ML w0(e) wm p.[n/ Gv sRRwsm d. a<fq,desre
'AC OX .0200 Well Cvor1. iar.0amenca most dYn a
RN as, wll owarr.
well devils'
ge to provide additional well site details or well
Po mtech additional Pages if r eeessmy.
us farm within 30 days of completion of well
sources, Information Processing Unit,
Center, Raleigh, NC 27699-1617
'' In addition to sending the form to the address in
)f this found within 30 days of completion of wall
:a, Underground Inicalon Control Program,
Center, Raleigh, NC 27699-1636
on Wells:
Drm within 30 days of completion of
health department of Ute county where
Por. Ow -I Nonh Caroline Depwnom.1E.A.nmrnt and NYwrl R ...... b- Dmfiem of W4.r fto..as R.vvrd Augwt 2013