Well CompletionHARN_. i DEPARTMENT OF PUBLIC HEALTH i-AMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: _�� Parcel #: Application #: Subdivision: Lot #:
Applicant Name: _ "a Ue- A)OOde47.((
Address:
Type of Facility Served by Well: SFD
Sewage System: -Z-0/0 &11-�
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 A l
Gr ting Inspection essed Date
Grouting self -certified by driller GW -I provided? Yes ❑ No
See attachment for construction sketch
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 StateAgel��O�-� _ �� Date
See Attachment for complet-ion sketch
WELL CERTIFICATE OF COMPLETION
Dates Application
#: Well Contractor:
Applicant Name:
Address:
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: _ glint at ft.
Disinfection: Type
Amount
Water Zone (depth)
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:
Authorized StateAgel��O�-� _ �� Date
See Attachment for complet-ion sketch
Application #: Applicant Name: Subdivision: Lot #:
Well Completion Sketch
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