New Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
1��sMas/ PIN M _ Parcel #: _ Application Subdivision:W- Lot tl:
Applicant Name: Z—Z'g f f ,S/0/'4tct (�
Address: 1 o I 131tbr>�ic, AeA04 V /M �t/�.- J /d -C, Z75VCD
Type of Facility Served by Well: SFD
Sewage System: —Z% /?4A- t
Permit Conditions:
General Permit Conditions:
• Drinking water supply well construction must meet I SA 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 Age t Date ^/ -
Gr}tion Witase �J�ate 17-41-01a.
GAroutng /
(�
self -certified by driller GW -1 provided? es ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: a3/6y l- Application #: J�e Well Contractor: fr--AC&,,� N
w-5-35291 Pocte we. Lt
Applicant Name: S(4�
SEC�41
Address: tot 6tooaly
,vk", 0..d 1{vu'7 Spn�'s, .✓c r -75V6
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 _ fl.
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 Dale:
Remarks:
Well Head Information
Casing Height: �(s(above finished grade) Access Port: ✓ Vent Stack:
Well ID Tag:
_
Pun ID Tag: Sampling Tap: �✓ Backflow Prevemer:
Sample Taken? 1-1YesNo
Well Head properly sealed: el
Remarks: _
Authorized StateAgen
Date Cj3 0
See
Vie""'-+
Attachment for comp
ton sketch,
1-5-352-1` I
App ,cation ::
Well Construction Sketch
Well Completion Sketch
sraA;61
Applicant Name: Subdivision: Lot
_ 4'D
f CoA;
M,
'Fo%J-t,6 cu&, z>u
1
GY'd�,,
�u
Dec. 22. 2016 4:21P
,,1a., NRECggD
ihla Arm can ba red for 01.51. oTnrdUPI. vegr
L Well Contractor Information:
Cir -� M�so✓I
Well Con.actor N..
NC Wag Cono-cr& Coni& -tion Number
N.W. Poole Well & Pump Co.
Comp®yNane
2. Well Cuosrruetion Permit A:
Llrr, all opplimb/e "it com".r.. perm,-(l,c. County, Smre. Podvnce, ere)
3. Well Use (check well use):
DAgdcultural OMunicip rupublic
OOeelhetmgl (HeaeinglCooling Supply) \>Mesiden6al Water Supply (single)
Olndustrial/Commercial OReciden6al Water Supply (shared)
OAquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
DAquifer Test DStormayster orainage
DExpermenml Technology DSubsidence Control
OGeothermal (Closed Inop) OTmcaf
4. Date Well(s) Completed: _L
S. Well Location:
PeciliN/OwncrNamc Facility IDP (dapp6cable)
f` r
Physical Address, Ciry, /and Zip
14Ccr- n� ,
County Force] ldcvd6adoo 140 (PIN)
Sb. Latitude sod Longitude to drgrees/minuteapecoade or decimal degrees:
(ifw�eg field. one le ilaog is suffi.iebc)
ifJ n
1 y y
-r
-4(VQ� I 1 N ~'I C1 -U U -1S W
6. I5 (are) the well(s)YpMermanent or DTempurary
7. Is this a repair to an existing well: OYcs or -�Mo
//rhr, Is a mpvin jell .-,.brown wdl comrrverlon Iq/ornlanon and erplo/n rhe roPoro v/rha
repvi. undo, all remarks a.nrpn or on ria Dack of ,tits jorm.
B. Number of wells constructed:
Por malllpla /nlcrlion or non warrrsupp(y we!!r ONLFwI/h rhe roma eomtrucdon. you con
ru6rnaonejvrw.
9. Total well depth below lead outface:
For muMpre wells b# afl deplhe fdArem (emmp/e-J(a J@200
ond2@100')
lo. Static water level below mp of casing:
!!jw-r level Is abase Ms/ng.
We "+" (R-)
11. Borehole diameter: (�_ (tet )
12. Well conotarction method: _ rK C9 T, y
(i.a, avam rotary, ..a, cheat puab, a .) 7
No. 4513 P. 1
Fot Iduod Um ONLY:
ilei � a.-�lr�i'197(�"P�k1S
22. Cerdfrcedon:
Srgvaw¢ofCenlaw Weu Con.acmr Dere
BY living Ih/s jonn, I herely -HIO, rhai rhe wells) w, (ware) eonarrucrad In aeeordanra
wllh (JA NCAC 02C.0/00 or IJA NCAC 02C.0200 Well Camrrvcnan Smadard and liar v
copy ojlhrr mcnsdhvs been pro./dad to he wall owner.
23, Site diagram or additional on details:
You may use the back of this page to provide additional well site demils or well
construction details., You may also attach additional pages ifnecrssmy,
24. Shinnidal loshmctiom:
24s. For ll Wells; Submit this form within 30 days of completion of well
construction to the fbllomng!
Dlvtslon of Water Quality, Information Processing Unit,
1617 Mag Service Center, Raleigh, NC 276:9-1617
24b. Far ]meed.. Wd1s: In addition to sending the form to the address in 243
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
JwATSRSUPQLyWELLS ONLX:1636 Mag SeMce Center, Raleigh, NC 27699-1636
(Spin) ��-/ Method of testi �O 245 For Wattva remh..,n.i w.n.. (n addition m sending Ne Cotm to
the addreas(es) above, also submit one copy of this form within 30 days of
fection type: qi< Amount:/_ / b completion of well construction to the county health depamnrnt of the county
where constructed.
Form GW -1 North Carolina Depaosm nt ofEnvimamaat and Nanual Resoureee
Division afweur Quliry Aa-isrd lm.2013
�xLZ�i)if •'�.,' . .�Y. .mJi" .�'�. nS��i6��,�ii�.`„�eo7 '
MCA a"l�l�P7A 113' 1�
22. Cerdfrcedon:
Srgvaw¢ofCenlaw Weu Con.acmr Dere
BY living Ih/s jonn, I herely -HIO, rhai rhe wells) w, (ware) eonarrucrad In aeeordanra
wllh (JA NCAC 02C.0/00 or IJA NCAC 02C.0200 Well Camrrvcnan Smadard and liar v
copy ojlhrr mcnsdhvs been pro./dad to he wall owner.
23, Site diagram or additional on details:
You may use the back of this page to provide additional well site demils or well
construction details., You may also attach additional pages ifnecrssmy,
24. Shinnidal loshmctiom:
24s. For ll Wells; Submit this form within 30 days of completion of well
construction to the fbllomng!
Dlvtslon of Water Quality, Information Processing Unit,
1617 Mag Service Center, Raleigh, NC 276:9-1617
24b. Far ]meed.. Wd1s: In addition to sending the form to the address in 243
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
JwATSRSUPQLyWELLS ONLX:1636 Mag SeMce Center, Raleigh, NC 27699-1636
(Spin) ��-/ Method of testi �O 245 For Wattva remh..,n.i w.n.. (n addition m sending Ne Cotm to
the addreas(es) above, also submit one copy of this form within 30 days of
fection type: qi< Amount:/_ / b completion of well construction to the county health depamnrnt of the county
where constructed.
Form GW -1 North Carolina Depaosm nt ofEnvimamaat and Nanual Resoureee
Division afweur Quliry Aa-isrd lm.2013