Well CompletionHARNFTT DEPARTMENT OF PUBLIC HEALTH PF,RMIT
TOC STRUCT A DRINKING WATER SUPPLI ELL
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PIN #: Parcel #: Application #: - Subdivision: — Lot #:
Applicant Name: j0Jh,)NLL-'
Address: 4-55-/Ua//4.,f LV 2,8 i3 `l
Type of Facility Served by Well: Sfi& :9 tJel�"
Sewage System: Zisz% aAvel
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 Air. t ) Dat Jam/
ro
Gg Inspection Witnessed Date
Grouting self -certified by driller GW -1 provided? E21fes ❑ No
See attachment for construction sketch
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WELL CERTIFICATE
rO,F_�COMPLETION
Dale: ZAyr�� Application #: Well Contractor: L)�t-' 4.
Applicant Name: sf'✓�
Address:Li-
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To
From To
From To
Inspector:
Remarks:
Date Drilled: Total Depth: _ Replacement Well? ❑ Yes ❑ No
Top of Casing is _ in. above surface. Yield: gpm at _ ft.
Amount
Casine
From _ To
Diameter: Material:
From To
Diameter: Material:
From _ To
Grout
From 0 To
Thickness: Material: Method: _
From To
Thickness:
Diameter: Material: _ Thickness:
On Hold Date: Release Date:
Material: Method: _
From To _
Material: Method:
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 A nt Date 2'iS -tt'7
See Attachment for compl ' n sketch
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pplication #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch
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