New Well CompletionHARNF—" DEPARTMENT OF PUBLIC HEALTH F -MIT
?,?TO CG_ TRUCT A DRINKING WATER SUPPLY —,'LL
l�t�-b�aO'p0° o2tsaS'`►°°°'l�-S-yo$66
PIN #: Parcel #:/ L_ Application #': _ Subdivision: _ Lot #:
Annlicant Name: AN AON Z?4' ek
1 :ss:-PL7 CKocuntl(aJ �00^r /.r.c. 2,333Y
Type of Facility Served by Well: SFD
Sewage System:X
Permit Conditions: OQ
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 AeEnt _ /' 1Aj�4,a�r Date 3 -X —
Grouting Inspection Wised Date _
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor
! icant Name: _
A__ress: _
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)
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:
Aatnorized State Age , Dates Z IT- ti
See Attachment for compleKon sketch
Appligation
Applicant Name
��:��13�
/. ft*—
Well Construction Sketch
Subdivision: Lot it:
`' ' Completion Sketch
Joe
May 08 1712:34p Barefools Well Drill.
WELL CONSTRUCTION RECORD 9W-11
1. Well Cant"/I cigar information, L
W[II Caunaw Name
NC WeII CootWtor/Cenifiudcn Number
anyOIL
Company Namc
2. Well Comlraction Permit N:
bsl a'I appNeoble w[fl mwsamoom pernniL• (i,a. WC. Crmnry, Gale. Varian. efe J
3. Well Use (cheek well ase):
[)M cipaltPubhc
(Heating/Cooling SupplY) esirkntial Water Supply Atingle)
ommemial DResidentiel Water Supply (Shored)
Recharge OGroundwmet Remodiation
Storage and Recovery OSalinity Barrer
iI Tahnslogy E)Subsidenee Control
(Closed Loop) OTraccr
421
4. Date W tllls) Completed: Well IDN
5a. Well Location
Faeitityovw.cr H-0 Facility We (if applicable)
Physics address, CitS', d zip
t"I G� n f
Cmmy Parcel Idenlif estion No. (PIN)
5b. Latitude and longitude in degrees minuleakeeonds or decimal degrees:
(if well field, ane loathing is sufficient)
6.10m) the wellW rermanent or 13Temporary
7, Is this• repelrtome insisting well: E3ves or 12ivo
Ifthv . a repair, fd1 out Mown well coonmvim kob'stafbn and espial" the ooh, of1he
repair ander u21 mwo kit suction or do the bock qf1h1s fast.
8. For GeoprobNDPT or Closed -Loop Geothermal Wella having theme
communion, onlyI GW -1 is needed. Indicate TOTAL NUMBER of wells
drilkd: (/n
9. Ton( well depth belaw land surface: �✓� (ft.)
for malliple wells ibr all dephs Ifdigerenl (uomple. 3&00 • and 2d4100)
10. Static wafer level below top or easing: U (RJ
Ifwwe I'M cis ove..ring. vsr "."
Il. Borehole diameter:
12. Well cmatruetion method:
rt, cease, `maty, able, three posh, nc)
910% .48 p.t
For Internal Use Only:
n.
A.
n.
A.
22. Certification:
ni�of tried Well �=na�eamirr 5
to
By narNng Ihu /alai, ! hrr[bY an?/y dmf rho well ft) war (were) conarverrd to nttwManca
with 15A NCAC 62C.0100 or 13A NCAC 02C.0700 troll Crwvn etwo GwdanN acrd lits' a
curry of Ihu record hes been provided In the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well she details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wella: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Prociaing Unit,
1617 Mail Seim Center, Raleigh, NC 27699-1617
Mb. For Inimftmf Wells: 1. addition to sending the form to Ike address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division ofwater Resources, Underground (ejection Control Program,
FOR NATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
i
Iia. Yield Igpvll Method Mtest: Dull For Water Snitch ls (iWells: to addition
the sending the form
the addresses) above, also submit
onn e copy of this Corm within 30 days of
13b. Disinfection type: Amount: oomplelion of Well conatmUion to dic county health department of the county
where constructed.
Farm GW -1 Noah Cx Iina Depanmenl of Environmental Quality - Division or wa¢r Resources Revisal 2-22-2016
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