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Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT 95y�'67 -:r77-7.1' TO CONSTRUCT A DRINKING WATER SUPPLY WELL /G-5-. PIN #: Parcel #: Application #: 1Z "P Subdivision: _ Lot #: l Applicant Name: _,&W 47�5)�Pe<_ e4,e e, , ,9 Address: 36G / /, e . g 83 Y$ Type of Facility Served by Well: SFD Sewage System: Permit Conditions: General Permit Conditions: • Drinking water supply well construction must nice( 15A NCAC 02C.10() 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 S ,/ /J�ii2M$ Authorized State Agee[_., i; y,....� l �"'� r > Date &'2�6G Grouting Inspection Witnessed Date El Grouting self -certified by driller GW -I 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? El Yes El No Static Water Level: Top of Casing is _ in. above surface. Yield: _ gpm at _ ft. Disinfection: Type_ Amount Water Zone (depth) From To From _ To _ From To Inspector: _ Remarks: Casing Front _ To _ Diameter: _ Material: _ Thickness From To _ Diameter: _ Material: Thickness: From To _ Diameter: _ Material: Thickness: On Hold Date: _ Release Date: Grout From 0 To _ Material: _ Method: _ From To _ Material: _ Method: _ From To _ Material: Method: Well Head Information Casing Height: _ (above finished grade) Access Port: Vent Stack: _ Well 1D Tag: _ Pump ID Tag: _ Sampling Tap: Backflow Preventer: Sample Taken? ❑ Yes ❑ No Well Head properly sealed: _ Remarks: Authorized State Agen Date % —! 7 See Attachment for complet sketch Application #: Applicant Name: Subdivision: Well Construction Sketch Lot #: p6m p.A Well Completion Sketch Jun 20 17 08:05a WELL CONSTRUCTION RECORD (GW -D L Wed Cunhsmr IrformaEmo• win camemr rtame Lag - /# NC [oo®oor fau5®onNi// CNC fP!' 2. Weil Cunstrondvo Puma 9: (icoll�pumWe vRrnmnaaiawpermirr (se. UNC Lamy;.SY@e Ymavrq dc/ 3_ Wen Use (check welt me): O�M/.;�dPA��Poblic ( ngsopply) l�°LW Water supply(soYJc) av>maual EIo id water s ppfy(sbmd) [3Cmmmdwatn Rawdradon Recovery OSalmity Barrier (Clued Law) 4_ Ilan, WW.) Gmgddod_ 7 /eYU 1/ / wa S. Well Lontioo: 7(/ n"�[ i � 11 o V1 rU l � m run me ii L t Advcn Cris: andIrap e Ln(i County Pnal Idem6mtimlVo. (PB'1) P.1 Print Form For Internal Use OnFj ISR r¢ R I n. UliRCNSWG(fw mrborrd meli vo mae¢wax nea cAslrc oeTuewc 1a DidxEm R R a Ht513V m numn� su R R m taUT To arA7F8L11. R � ¢ d c are R R R ¢ Nn/CRAVPI PACKbf kl m atAis>atee. R ¢ ¢ ¢ NOMMU ©RM ©p_M- Q 5b. t.autude zed longitude in degreeslensuk /amnds orderasoal degrees: I (ifweLL field, ave lselloog cavfficm) 22 Ccrtifivtio ! N W /J r 6fiDr � 6. L1(art)the wrll(s�L Fcrmaoeot or ❑,Temporary S oFCetfied Wea Cgnehauo< Qc¢ this repay m an ey -V g dalarw, I lively —26 dm 7. Is thMe aeB(a) vin (easy anmhvrd b aam,l eris�g v"-- ©Yes or o WahJ5A NGC A?C_plop m l5A ArAC tCrC-OM ®d/CautrammM j d. rmAebela Iltba is a npe.fdfovr Inman avLoaaoaalm bfwmmiar mdeapfaas dm mmrrvldre mfd'aldearrcwd 6orlrrnpmvidedmdm adloano. spur roarer OW case its remba or w W book fr &)tuna. 23. Site dogtam tar eddltioual well detftz For CeeprobdDPf err dosed-li p GmWer®1 Weds having the sane You cony use the Lade of this page to provide additional w B site derails or well Construction, only l/ W -lis -ceded. Idimle TOTAL NUMBER ofvells cnwmactiondemds Ym yaboattrehadditimalpng ifno«ary. dn0od SUBMITTAL 7NSMUCnONS 9. Total well depth Dhow land surface: (pt_) Formdayhtmdsli¢e![rT(e�^ple-7®Z0//0,,asIIQ7o 10. Static water level below tap of casing: e]'�I ((L) yaaar la.au ahmw � aR -... 24t For AR Wells Submit [his from within 30 days of rampimon of well construction to the following: Division of Water Resovees, Information Psoeesiag Unto 1617 Ad it Sca ioe Cemm, RaWrA NC 276"-1617 11. Borehole diameRr- / /! (n) 24b. For loiemon Wells: In addition to s ding the farm to do edds in 24a 12.W.R roaatrsmdan mrma._ m,,,� %(�j}c I- . �J• y. j 'r above, also svbmir ow copy of this firm within 30 days of o mpktim of veli mmtructioo Iothe foQosvmg: (i.c sugr, mory, o6k davrpmh, dcl Ij Divf6foo of Wle is Resmxncm, Underground Iojedioa Coobvi Program, FOR WATER SUPPLY WELLS c ONLY: 1636 Md Service Cmar, Rideigis, NC TM91-16M 13a- Yield (gpm) rddbod of last: 24c. For Waw Som dy & Impaction Wells: In addition to sending the form to the address(au) above, also nebmrt we eeQy of this form within 30 days of 13b. Dhhdacdoa hype AI: Amount: mngIcbw of well candrontion to the aoiy health dgndmcnt of the county awhve oa.d...,..e F. GW -1 lemlh Csofase Oamtuun-FFmuoeoe WQuality-Di ism of Wab Rrmeser Barbed 2-:2-2016