Well CompetionHAR'-,TT DEPARTMENT OF PUBLIC HEALTI ,RMIT
TO .4STRUCT A DRINKING WATER SUPPL. NELL
0(�3.t-97-/Yap ps-Qtes-otoza� (6-{
PIN #: Parcel #: Application # 3SI%� Subdivision: _ Lot #:
Applicant Name:
Address: IZ33
Type of Facility Served by Well: SFD
Sewage System: 4.1,/
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 Z'
1 G
Authorized State Ag t �t Date
Grouting Inspection Wi essed 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:
Date Drilled:
Total Depth:
_ Replacement Well? ❑ Yes
❑ No
Static Water
Level:
_ Top of Casing is
_ in. above
surface. Yield:
_ gpm at
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:1Z�n (above finished grade) cess Port: ✓ Vent Stack: _✓
Well ID Tag: — mp ID Tag: v Sampling Tap: �� Backilow Preventer: _
Sample Taken? es E]No Well Head properly sealed:
Remarks:
Authorized State ent G�^Date
See Attachment for comp a on sketch
I. -S-351 V(. SAl�1�5C1*141*vO
Application #: Applicant Nam, Subdivision: Lot i
Well Construction Sketch
Well Completion Sketch
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Sep 1516 C 1:29p Grady Poole Well Company
WELL CONSTRUCTION RECORD
This farm can he used forsingle of multiple wets
1, Well Contractor Informations
Jason Poole
Wdl C'otamcmf Name
2279-A
NC Well Cauoacmr Certification NumMr
Grady Poole Well & Pump Co., Inc.
C�mpany Name
2. Well Construction Permit p:
Ls+ aOupphvetbie wdl permm- (e. C'oanry•SIM ✓mien r, AJ ofti n, arc)
3. Well Use (cheekwdl use):
OAgriculbual OMmicipd./Public
❑Geothermal (Heatmgt:sdmg Supply) ElResidential Water Supply (single)
71ndustod/Commercial ❑Residential Water Supply (shared)
O Aquifer Recharge
OGmundwatcr Remediation
❑Aquifer Smraga and Recovery
OSalmity Barrier
❑Aquifer Tcst
OStormwater Drainage
OEaperimental Technology
❑Subsidence Control
OGemhermal(Closed Loop)
❑Tracer
4. Date Well(s) Completed: 091)216 Wall
So. Well Location:
Steve Scardino
FaitiyrOwnrr Name
Facility IDA (ifappliciblc)
SR 1405,Oakridge Duncan Rd.
Physical Addicos, City, and Zip
Hamett 0635-97-1400
Coamy
Pence) ldcmi6ettion NO. (WN)
5b. Latitude and Longjmde in drgrccsrmkmIcslseeouds or decimal degrees:
(if wdl Feld, one Ialloog is sur mem)
6. Is (are) lhewell(s): OPormanent or ❑Temporary
7. Is this a repair to an existing well: Oyes ar EINo
It his iso rtpaN„fill oar known se!/ cronarrvcrmn infmnasaw and erp/uin eh. rrou rc n(rnv
rcpuir under se21 remarkr.reeaon tarter +nz hock o/J+is7orm.
R. Number of wells constructed: One
h, w-v!sirh• iryxvum m narnxv/cr ny�p!yx•crG ON6Y r ul: raw s'amc evnrnuMnn, yen tan
m5rvh ane !wm _-t/
9. Total well depth below land surface•, /7(/X 7 (ft.)
For moffipie wo!!s riu u/l drplse ii J(lp!rent (cso+�pls•�]r�2on' nmJ 2vIPT1
10. Searle water level below top of casing:
I/nater/nil rsnbnsc,:arrng we ••i'
11. Borehole diameter: 6 (in.)
12. Well construction method: air rotary
(c auger, ru:my, ;*,,. direcr pnsh etc)
919-266-0188 p.2
for Imennl Use ONLY:
14. WATER ZONES
FROM I To
nESCRR'rtON
0 fl. Y
i
o.
R
15. OUTER CASING ifor moYieudwdls OR UMER ifa 'ohne
FROM TO INAMEI'RR TIIICKN MATED L
0 R
(L 6 a
16. INNER CASING OR TUBING wlhermdchsed-Iw
PROM TO
OIAMETFA i1DCe"NPES MaTTRt4e
ft.
IL s
I7 -SCREEN
PROM To
OIANF: rEn St.OT [rLE TIIICIWE55 MATF]iLV.
fl. R
in
fn. h
in
I& GROUT
FROM To
MATWAL Fa1PLACf.MENr ¢1EnnOUSAMOUNr
0 D' 20
R Portland & Gravity
ft,
ft- Screenings
19. SANDIGRM1VEL PACKifa We
PROM n1
MATtR1Al. EMPLACfM[\T MaTNon
A,
h
R
h.
26. DRILUNG LOG efl a=h adi idated im.leffnecesa
mom To
0 N,
DCSCR IONwlm. hardneu adV.tk nin sec ac
it topsoil
n.
R
s
h
R +
n.
R.
R
as.
&
R
n.
R
21. REMARKS
22, Ce-fieation:
e F fir{
091% ✓ 12016
SiDsv of emfied Well r Dam
1)r si u+g lbs Inner. ! irxqu ctr/!j'v /Iw+ rhe xr/rYj u•or fxwref ci, ruled in meo.•deneu
nuh.kCA(''21 11!1p yr I.A hrAF 62C fl ]r,/' Nd! ('answcTior. Stand:•nla nM rhea a
cwy.jrhrr ricers here hewn provided m dix svelr umner.
23. Site diagram or additional well details:
You may use the back of thus page to provide additional well site details in well
cunsTmetion details. You may also attach additional pages if necessay.
SUBMITTAL INSTUCTIONS
24a. Fur All Wells: Submit this tbrm within 30 days of completion of well
conanuenon to the following:
Divm' mn of Water Resources, Tnformation Processing Unit,
1617 hfail Service Center, Raleigh, NC 27699-1617
24b. For laiection Wells ONLY: 1. addition to sending the home to the address in
24aabove, also submit a copy of this form within 30 days of completion of Fret
cm5tnmion to the Ibllowing.
UiTision of Water Resuurcm, Underground Injection Coastal Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center. Raleigh, NC 276"-1636
Blow 24a For Water SupP1Y & Injection Wells:
M. Yield (oyer) Method of test: Also submit one copy of [Itis fain within 30 days ofcompletion of
HTH 1 Lb. vett cominuctjm to the county health department of the county where
13ix Disinfection type:.M1onnC constructed
Farm Gu' -1 North Cwoli¢a DepaMrenloflFaironme¢I and Moral Reaowres—Diei1weof%ter Rem¢m� Raomil Aunaroe12a13