Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 8V-jaA0 Parcel #: Application Subdivision: _ Lot #:
Applicant Name: 01-4)t to :(1Q,L,— (' �BiCQ
Address: 211
—Y I # — 2't52S
Type of Facility Served by Well: SF
Sewage Syslem: If —A n&ljp
Permit Conditions:
General Permit Conditions:
• Drinking water supply well construction must meet 15A NCAC 020.100 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 nce of the well, may
subject this Permit to revocation GG
Authorized State ent
Grouting Inspection Wi sed 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: P Date Drilled: Total Depth: gLr Replacement Well? ❑ Yes ❑ No
Static Water Level: Top of Casing is in. above surface. Yield: 90 gpm at _ ft.
Disinfection: Type atry Amount
Water Zone (depth) Casing Grout
From To 94s� From _i To _ From 0 To
From To _ Diameter: 6%d Material: JmL Thickness: y0 Material:Po Method: /otLIV
From To From _ To From
Diameter: _ Material Thickness: Material: Method: _
From _ To _ Front 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 AgeaL G=�� Date `s^/Q-17
See Attachment for comOWtion sketch
Application #: Applicant Name: Subdivision: _ Lot #:
Well Construction Sketch
Well Completion Sketch
WELL CONSTRUCTION RECORD (C W-11
1. Well Contractor Information:
Jw��;n Qor��oo4_
Well Conurotor Name
Sore-4al)S 311711-A
NC Wau Coonamor Cemfimnoaxumbcr
Bgreroo'i's la/all IXr'llw
Company Name
2. Well Construction Permit N: I6-'� 38753
Lint all applicable well,ommoovs perm,, (.e. WC, Castro, Stme, porimnaa etc.)
3. Well Use (check well use):
CAgricuhurel OMunicipid Public
CG -thermal (Heating/Cooling Supply) Cdcai lmnal Water Supply (single)
Olndustrial/Commercial OResidential Water Supply (shared)
CAquifer Recharge OGroundwater Remediation
OAquifer Swage and Recovery OSalinity Barrier
CAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeotheonal (Heating/Cooli ag Return) OOther (explain under N21 F
4. Date Well(s) Completed: 1248 1{ Well IDN
5a. Well Location:
Max ,
1 Jer
Faoiity/() n NemsFacility IDH(ifapplicabk)
J.26 Upiley R -y,fs oZ75-.2 1
Phyocel Addr—, City, and Zip
Cowry Parcel Idenuficauon No. (PIN)
Print For
For Internal Use Only:
R / R
R R
I7. SCREEN
mom 1n DumereR
R R In.
R R In.
R. i R
R R
RI R
a
5b. Latitude and 10110tude in degrees/minutes/seconds or decimal degrees: I
(dwell field, one la4cus is suEcina) 22. Mom3S396 5 --N -79.6168 w I� 5 �6
p
6.1s(are)thewe0(s): (BPeromnent or OTempornry b,vr ofC ed Well Contractor Dau
�� By ngdng th, farm. I hereby cs ify that the WIN) wmr (were) comoected in oecordance
7. Is this a repair to an eristing wen: []Yes or W1Vo with ISANCAC 02C.0100 or ISANCAC 02C.0200 well Cowrrucdon Srandorde and rhm o
1fdu2 ie a fir, fill our kb. well cormractsan infmsonon and axpldn de nature ofthe copy offha remrd hm been provided to the well owner.
repair --*1 421 remarks section er on the back ofth, farm.
23. Site diagram or additional wen details:
8. For Geoprobe)DPT or Closed -Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, only 1 GW -1 is needed. Indicate TOTAL NUNSER of wells constitution details. You may also attach additional pages if necessary.
drilled:
6 SUBMITTAL INSTRUCTIONS
9. Total wen depth below land surface: R
242. For All Wells: Submit this form within 30 days P of completion of well
For multiple wells list all depths jd�erent (exargle-3(o)100'aM 2(gj1007 ( )
construction to the following:
10. Static water level below top of casing: (R)
Ifsmv, 1~1 is above caring,
11. Borehole diameter. ,1
12. Well constraetion method: ro iR r y
(i.e. auger, rotary, cable, direct push, ore.)!
Division of Water Remurces, Information proressiug Unit,
1617 Mail Service Center, Raleigh, NC 276WI617
246. For ;election Wells: In addition to sending the Jona to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WE1:IS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (grata) rX%J Method of test: _ 24e. For Water SuooN & in&ection wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
136. Disinfection type: —ho r M Amomt: N s completion of well construction to the county health department of the comely
where eonsnucted.
From GW -1 Norah CuolimD ssmunt ofEavuoemental
eP Qmlity- Division of Water Resaacea Revised 2-22-2016