Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PFUMIT
TO CC TRUCT A DRINKING WATER SUPPLY ;LL
L4 Omg, p�u qr;N
PIN #: Parcel Parcel #: CUIC11Eh Application #: Ln Subdivision: Lot #:
Applicant Name: Ocmlo. M+ICL�'E�j$h
Address: !kr4 Qr:Q Ln (N(. 53)
Type of Facility Served by Well: SFD
Sewage System: 2- 5%6 c,Jochton Sv"
Permit Conditions: )J¢.0 lob' i o�:IF �ki�
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 rev ay9 ti ���—
Authorized State en l" —Date 17-/o 11.", 6
Gro ng Inspection nessed i fi F sora c6Jd 4 Z6 -7 -
Grouting self -certified by driller GW -1 provided? EWKs ❑ 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:
Casine
From To
Diameter: _ Material:
From To
Diameter: Material:
From _ To
Diameter: Material:
On Hold Date: Release Date:
Thickness:
Thickness:
Thickness:
Grout
From 0 To _
Material: _ Method:
From To _
Material: Method:
From _ To
Material: Method:
Wasell Head Information
Cing Height:Z_n (above finished grade) Access Port: ✓ Vent Stack:
Well ID Tag: ✓ Pump ID Tag: —� Sampling Tap: ✓ Backflow Preventer:
Sample Taken? es ❑ No Well Head properly sealed: 4
Remarks:
Authorized State n Q Date O 1-4
See Attachment for co tion sketch
Application #: 4 -0600 -
Applicant Name: Subdivision: Lot #:
O"OL tlercA�, i.
Well Construction Sketch
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Well Completion Sketch
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5 REsrvENTUL WM"WWnIIUCnONR8CORD
Nath �Ima Dep�nt of Favirp�at and Natural Rcm noes -Division or Waco Qaahty
0�`®"�' wELL CONTRACTOR Cmrf FiCATmN A 2179
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We4 Contractor unowick" %aree
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anto cwpwwxa
"Fee Ek9druclor
sTREETAmRms SM McDougald Road
P"iRP—M,
.,•, r. CamMa 27546
CWar Tom SIMs Zlp Gude
SITE WElI. ID s "kat ft ��Ckz�'—_
f
STATEWEUPERANTip[Wp�g�f �-'(�--5-
DM or OTHER PERW 901 appW�)
WELL USE (Chock Appax wBox)• Reeldentlamater9upply
DATE
Ti1ECOOPLETED_ �.'� ✓ '0 AMO PMD
& WELL LOCATOMk j
CITY: COUN1v_%tjlr�>r
SASilsknLatRo., Parcel,Dp Cie)
TILAM SETRNG:
0Week qWM*gbft � ❑ Curer
LATITUDE .3 _ "% [jydk,�'
s-
LONGMJDE� - -rR—
Latitudalkwaimade somote wEa-r uTopographw map
(!010001011bM nada!bo Niwm on a USW bpo map and alachad to
9* Amm #nor tAfigl GPV
A ria • Yat•®
IL WELL DETALS:
a. TOTAL DEPT!:_ �8 (? /
b. DOES WELL REPLACEEXISTING WELL? YESD NQ®---�
a. WATER LEVEL Bebw Top of CaskV.
(U9a'r' If AbQw Top d
d. TOP OF CASINO IS I_ FT. Above Land Sariace-
'TOP of COBkVt nubutled aCorbelow land surface may require
9 VaF&mw b 4201000010000, with 15A NGAG 20.01 119. N
a. YIELD (We* --d 0 _ �7NOO OF TEST Al r
I& WATER ZONES (depth):
rrwt— —To� From Te
Fran_ f 9 � To,Li/, From To
From To From To
6 CASOM ThOwelosel
Flom C9 Depth `� R. k Weight
h
Froin Ta FL
Front To R
7. GRWIY: Depth - Material
Fmm Ta�R / l 's%5'
Frorn___To_ R_
FmnL _ To Ft
& SCAEEMk Depth . Dbnmtar got Sim Material
From—To R__Jn. T in.
RUN To R_im —m
From To Ft.___in. _ kL
9. SANOXMVEL PACK:
Depth size Maw"
From To A.
FWrOX To Ft,
Flinn To Ft
10. ORILLW40 LOG
From TO Fomtation Dowitphon
L_ _
11. REMARKS:
1001039M CERTIFY TWT THLS WELL WAS raxaTpucr13)WA Wfy"
'M XIIW=WELLC&-'9" CTXM STANDARM ANDTIATA COPY CETHLS
r amw NAS BEEN PROVIDED TO THE WELL oWig{
SIGNAPRE OF CV&nED WELL OWMAGTOR DATE
Romer W. Jackson
PRINTED NAME OF PERSON � TIE WELL
Subrnit the Odgk d to the Etfbion Of Water Qualify wfth6130 daps. AWI: kdomtaelon AW..