Well CompletionHARNPTT DEPARTMENT OF PUBLIC HEALTH PERMIT
TOC STRUCT A DRINKING WATER SUPPLI ELL
PIN #: 0693505050 Parcel #: 040693010301
Applicant Name: Stancil Builders Inc
Address: 510 Kirk Adams Road
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Application #: 17-5-40748 Subdivision: _ Lot #: 1
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 revo
Authorized State Aggnt ��}�jjjy �� G /%/q �(q,r(�p to g - 1,
Grouting Inspection With'essed Date _
El Grouting self -certified by driller GW -I provided? ❑ Yes F1 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 _ ft.
Disinfection: Type _ Amount
Water Zone (depth)
From _ To _
From _ To _
From To
Inspector: _
Remarks:
Casing
From To _
Diameter: _ Material:
From _ To
Diameter: _ Material:
From _ To _
Diameter: Material:
On Hold Date: _ Release Date:
Grout
From 0 To _
Thickness: _ Material: _ Method: _
From To _
Thickness: _ Material: _ Method: _
From To _
Thickness: _ Material: Method:
Well Head Information
Casing Height: (above finished grade) Access Port: --ief�- Vent Stack:
Well ID Tag: Pump ID Tag: ✓ Sampling Tap: ✓ / Backflow
Sample Taken es [-I No No Well Head properly sealed: /_
Remarks:
Authorized State A Date -7-1-7-17
WA 8!
See Attachment for com on sketch 26
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch
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Jul. 12. 2017S 2:37PWON F.CO D
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This form cul be used for tingle or multiple w.W
1. Well Contractor Information:
-Yell cwur''s��'.'r Nn.
as Cu+79
!"C Weil Cenaaetel CmiO..6oa Numbrr
N.W. Poole Well & Pump Co.
Conluotry Noe.
::. Well COnrli'aellaa Permit B:C�93e'�
W, ell appllw4le xul/ emullvrllan permU: or. Cowry, Sara, yadenee, ale.)
. Well Use (check well use):
': t7Agricullural OMtmicipal/Puhlid'
i ❑Geothermal (Hcaling/COeling Supply) �.csldentld Waler Supply (single)
I
i GinduArial/Commercial OResidentid Water Supply (shared)
OAquifer Recharge
OO/aundwater Remediatlon
OAquifer Storage and Recovery
175alinity Barer
17Aquifer Test
OStonnwaler Dralnaga
0Expetiinentel Technology
QSubsidence Control
OGeothermol (Closed Loop)
OTracu
4 -Date well($) Completed: 3 ail f'7 --
. well Location:
Fzoiliwloaner Namc Iy WY(if rppgaable)
F4V*vl Addreet, Cily, randZip
L-1 ;—g
CD0e7' Pored Ideodae.too ph (PM)
3b. Lotilude and Longitude In degreerlmtauieslucooda or decimal degrem:
(f lhcll bold, nae Iauleoo is wfgci.o0
35,491 —N
c. Is (are) the svdl(s ermaucut' or OTemporary
7.13 tlds a repair to an eilsdngwell: OYes or 110.
1ldnr a o np0tr, fill wr Mlmrn s elf cmulrtrcuon !q/armaoon and.cplaln Ike ronin o/lhe
�eparr under N11 ramorin rverlon art on Ih1 Daeh dJrNwJonn.
+, Number ofeveUs toustructed:._ I
!or nndffple b0eulo" or "ennrerp supply rib 01104.11h the ram. ww"feen, you eon
cu6rnil wlr form.
P. Total well depth. below land surface: ..� (fL)
For uOdrlp/an•11/11111 all depfal lJdfnm(aample. )WjW,.nfl®100')'
AD, Stalic a,nler level helm, top.of using: fh
rV"VNr frvef it 0D01.r caring. or¢"a•" ( )
3.t. Dcr fe;Ic dlamotcro -- (0_
. Well construction method:.
(;.a. eupaq relay, oeble� dvacl "pmt ala.)
,so ""'Y: No. 6536—P.
4XWA 31
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22. CerllRcadou:
�m� L 3 7r
61®utao Cerddedwell Caaaador pec
By 119n/ng ddr Jwm 1 herby eerlJy Ipnl'rhe vdl(r) war 011111 ronrburred In orrm drama
with ISA NCAMC.0100 art ISA NCAC 02C.0100 Nall Cmmmdrmu $mrtdardl and rh01 v
ropy a/Iblt rewld/we bempmvldvd l0 the well corner. �
23. Site dlagrator additional well details:
You may use the beck of [hid page 10 provide additional well Zito details or well
consWction ddtails., You may dso attach additional pages iPnecessary.
24. Submittal lestructious:
24o. For All Wern Submit this form within 30 days of completion of well
construction to the following:
- Dhdslou of}Vater Quality, lulormrdon processing Unit,
1617 Mau Service Center, Raleigh, NC27699.1617
24b. For I LU119n Wella: In addition to sending the fano to the address in 24a
above, also submit a. copy of this form within 30 days of compicuon of well
const uction to the fallowing:
Dlaisl0a of Water Quality, Underground lulecdoa Control Program,
' kJ, POR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center, f icigh, NC 27599-1636
330. Yield (gpm) O Method of feel:` 241. For Water 8uooly r@ .eolherm I W ill : In addition to spicing the form to
the addroes(es) above; deo submit one copy of (his form within 30 days of
`:36..Ulslnfecllun type: T I- a� Amounit completion' of well constru6on to the county healtl department of IIle cowtry
where wnstruded.
"e.n Qw.l Noah Carolina Depuhmem ofgovltonmpnt and Natural Resources - Division ofWslerall
� 0' Rcviscd1at12013
tee
L -MM
__Low
FT, M-1
nI Y-
A � � _ M K-
s _ � a
22. CerllRcadou:
�m� L 3 7r
61®utao Cerddedwell Caaaador pec
By 119n/ng ddr Jwm 1 herby eerlJy Ipnl'rhe vdl(r) war 011111 ronrburred In orrm drama
with ISA NCAMC.0100 art ISA NCAC 02C.0100 Nall Cmmmdrmu $mrtdardl and rh01 v
ropy a/Iblt rewld/we bempmvldvd l0 the well corner. �
23. Site dlagrator additional well details:
You may use the beck of [hid page 10 provide additional well Zito details or well
consWction ddtails., You may dso attach additional pages iPnecessary.
24. Submittal lestructious:
24o. For All Wern Submit this form within 30 days of completion of well
construction to the following:
- Dhdslou of}Vater Quality, lulormrdon processing Unit,
1617 Mau Service Center, Raleigh, NC27699.1617
24b. For I LU119n Wella: In addition to sending the fano to the address in 24a
above, also submit a. copy of this form within 30 days of compicuon of well
const uction to the fallowing:
Dlaisl0a of Water Quality, Underground lulecdoa Control Program,
' kJ, POR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center, f icigh, NC 27599-1636
330. Yield (gpm) O Method of feel:` 241. For Water 8uooly r@ .eolherm I W ill : In addition to spicing the form to
the addroes(es) above; deo submit one copy of (his form within 30 days of
`:36..Ulslnfecllun type: T I- a� Amounit completion' of well constru6on to the county healtl department of IIle cowtry
where wnstruded.
"e.n Qw.l Noah Carolina Depuhmem ofgovltonmpnt and Natural Resources - Division ofWslerall
� 0' Rcviscd1at12013