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Well Completion- Cannot sign off on other permits have not been picked upHARK—"T DEPARTMENT OF PUBLIC HEALTH "-'RMIT TO C. .STRUCT A DRINKING WATER SUPPL] ELL 6�jL�7-It2iS.oa'�` S�Ido°t't° /7. PIN #: Parcel W. Application 7 Subdivision: _ Lot #: Applicant Name: 2[Z. Address: 17nQ$ N aT L�GGroSfrL N . C. 275V4 Type of Facility Served by Well: SFD Sewage System: _269 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 Stateent Grouting Inspection nessed Date ❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No See attachment for construction sketch II� ,,,�y WELL CERTIFICATE OF COMPLETION Date: 6-9.17 Application N:-irei Well Contractor: Applicant Name: Address: _ Directions to Site: Use of Well: Date Drilled: —Total Depth: _ Replacement Well? ElYes E]No Static Water Level: _ Top of Casing is _ in. above surface. Yield: gpm at Disinfection: Type _ Amount _ Water Zone (death) 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 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 At yr[� P Date See Attachment for comm sketch I /-s -YC9EF15 Application #: Applicant Name: Subdivision: Well Construction Sketch W:Z:4 t LD J, C (n U-5� , — Well Completion Sketch 11 s �I�Cat itp Lot #: 3,7- 1 )r-fz, aZ &- 1-13."5- Y3,al o-cQ__.C-'iA- 2,p WELL CONSTRUCTION RECORD (GW -1) I. Well Contractor information; Y�I (A/ 1 Well Contractor N a 9 (3-h-_ NC Well Cuttactot CeniBwtion Numbed _W; (Ii�aY(�S J/JCII Or;lliq q Company Name J p 2. Well Construction Permit 0: 1 / — 9 6 f yf( list all opplicobfe well ainispaedm.permirs 0•a. IC. Coun(y, Stara. Variance. sec) 3, Well Use (check well use): [3Municipal/Public (Heating/Cooling Supply)Residentiol Water Supply (single) 3ramoreial Rwidendal Water Supply (&hazed) Recharge ©Groundwater Ramediation Storage and Recovery [)Salinity, Harrier Test [Smrmwater Drainage Data[ Technology [)Subsidence Control nal (Closed u0p) OTraeer 4. Date Well(s) Completed: (0-6 - I q Well )[D# Sa. Well Location: 57�gna%ure- Home BL%1 6k,S Fadi /Owna Neste Facility ID# (if applicable) 7\�16ck C�Ili wl-, tj Kofi Physical Address, City, and Zip of Pb -1506-0066 Count' Parcel Ideatification No. (PM) 5b. Latitude and longitude in degrees/minuteS/seconds or decimal degrees: (ifwcn field, one laolong is suf cletu) 3S° Ir- Ltiiff N r7ff0g6-0,5- W 6. 13(are) the weu(s)ocrmanent or E3Ttrnporary 7. Is this s repair to an existing well: Dyes orNo If this Is a repair, fill 0u1 Mown well cvinrnu 6s. infnrmalimr and espfain rhe natare o/rhe repair under #21 r ni.,Js recl(on or on lhd hack of j4&'fdrm. 8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same construction, only 1_ GW -1 is needed, Indicate TOTAL NUMBER of wells For Internal Us Only: O I. 11. WATF3t 7L1 FROM TO DMCRIPTION 13. Well constructionm P�r1 construction ethod: r• O �! ✓ SA n / ret tie rt. I Dona action to the ' 1S. OUT%R CASI or In -"8 wHk OR LINER • cable mu1A t FROM TO nMaTER I THmRNx9a MATERIAL —I n' a 16. INNER CASIN n. 1a.1-�-CHYib VC - OR TUBING ebthsrm I dined -Ino FRUM TO Wafd6TRR TtOCKN6&S MATER4L fr, It. in. n. n. n. completion of well DIAMETER SLOT812M 116CXNZSS MATERIAL l '. in., otPO RSAXWGP-&VZY MATERIAL EMPLACEMENT` METHOD ® AMOUNT,2 n. eenI' G Y TYAv' . n. QVE7 AC8 rfa ]kabla FROM TO MATERIAL METHOD of Oft. fr' r - n r n. n. 20. DRILLING LO •Itach addltlonal obecu H ner FROM TO/ 5�MKACRMIINT DESCRIPTION robe betketreft. n. 3 raveR.ft tit 21. REMIIUI S 22. Certification: 6 17 Date gy 'Wn q rhi..fnrm, hereby Certify that the walls) was (were) mnatructed In aceordonce with J5A NCAC 02C. f 00 or 15A NCAC 02C.0200 Well Constrrmrion 5landards and that a copy of rho record has t ben provided to the well owner. 23. Site diagram ligaddittonal well details: You may use the b of this page to provide additional well site details or well consWetion details, I You may also attach additional pages if necessary 9. Total well depth below land surface: 2.I0_ (ft) Ada. For All Wel Formuloeld welU liardlldplhr lfd(derenr(irample-3(d220^00'and 2®)00') construction to the 10. Static water level below top of casing: I d (R.) Division Jfwater level a abdve casing, we "+" Ifir Al. Borehole diameter:_ (In.J ldb. For Infection 13. Well constructionm P�r1 construction ethod: r• O �! ✓ above, also submit — (i.e. auger, otary, cable, ulree[ptuh, etc.) r Dona action to the ' Division of Will FOR WATER SUPPLY WELLS ONLY: 1636 13a. Yield (gpm) /o Method of test: 24c. For Water Sr lL 1 � T the sddrvn(es) ab, 13b. Disinfection type: 1� Amount:%IL completion of well wfiere constructed. Submit this form within 30 days of completion of well ater Resources, Information Processing Unit, Service Center, Raleigh, NC 37699-1617 Is: In addition to sending the form to the address in 2Ae copy of this form within 30 days of completion of well Resources, Underground Injection Control Program, all Service Center, Raleigh, NC 27699-1636 LY & IQ ced-0 Wells; In addition to sending the foam to , also submit one copy of this foma within 30 days of instruction to the county health department of the county Foto OW -1 North Carolina Departrnent of Environmental Quality . Division o*atar Resources Revlsed 2.22-2016