Well CompletionHARM -T DEPARTMENT OF PUBLIC HEALTH r' RMIT
TO C% ,STRUCT A DRINKING WATER SUPPLI ELL
PIN #: 0681 31 8544 Parcel #: 110681 0005 09 Application #: 17-5-41248R Subdivision: Lot #:
Applicant Name: Clayton Homes of Sanford
Address: Sheriff Johnson Rd. (SR 1516)
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
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 rev
Authorized State A t i I Date S- 27-1'7
Grogting Inspection W nessed L%'iAs r i�✓�i/S Date O o a t
Eg'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? E] Yes
E] No
Static Water
Level
_ Top of Casing is
_ in. above
surface. Yield:
gpm at _ ft.
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: above finished grade)s Pon. V inStack: _✓
Well ID Tag: Pum Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ONo Well Head properly sealed:
Remarks: Ltcot ryVW.E fc Je_ L.Jtvn Povxr
Authorized State A nt G % ZDa
See Attachment for com n sketch`c',�'%9�,I
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch
�
rJe.�
will
• II0AL
t=ron
2
0
• 56<£
Fro..+
Prp�{)
�% z
• 10(oL4
�cor1
tn,d
v
u
�
of
iGpEic.
G':Gl�
���
,I N'u-W WELC
JL VPen Cotimdnr iw'foz..io -
b-,', 1 mnwess
yv c zjf 2�'6d—fj
Well t•�Ca2i0czriesiA—o
ZJ IJ MAWe3S a-�Sam's
�Q[G]7 131i L2Q�:ETEAfhOSFaaLS iti IIC Cs ySL'ril_Purl L
¢imiculasal yJ�jp_lj��Fc
OC-oibama (H-tal tn.,Te,o SQPPIy) y 1 tii*ma-&ppay(sge)
okft liaLrmmmmw ORcddantial W-wSappt,-
OAVifarRedwV QC>inu watErRwodafim
OAgnif-SMTA-. amd?lamtay OSaffnayBaniPr
Mquia Test 0SYmmtr.at=Dmm3sp
Oi=l autd Tcc moioeS o3abs mm Control
Moods imd(CImadLoop) OTt =
4. Date WtWs) CmEgktd"" LD1rJ WCUI))s
Sa MICH 7.nrnne
C/,* %Y IV Hold o / e p�¢Id
Fatffi�l M---CEr.PEzbL:)
tln a�?.ddc�, Cay, md7m -- - --- --
Camey Faces, 9 rifer \a (PR,)
5.a..rs,a..ZSdl��iadeg' secauds ordeaa&sl dem
rdmeff sad, opt= „=ys=ffim�I
35 25 W
6•Is(ata)tt�erli(sT�nent ar OTempo,
OL`�3 Flo
re-txv
:-see•: ��: -a. r
7. Istlosm '���- OYes ar �
lidnsisa:¢p�rh8wt6ramraIIaaupadty,rnjws*aam.adag6vae6�.naocag�
Br asps �i�. r r+emis FIs mar �) ,.� („oy o�mmeaia �d�
sB+23@XCaCddCAIOO�ISdId�}C Oi.Q�7}9etr^- ---c,dU,�e
+ePsr �a+d®'g3.i >a�sara» or o0 BaP,�Fcfd,Ejmm.
a+�$r�rnemdrgbee�Iyosidrdrn�wdiwm¢ - --
&For Geopan6a`IIY%orOme&lmopG lWeRshning th samo
2i SiLedraga$oa-a>IvaeH detm7s
You amya Iha baai Of this pagetopflsukaddifi a1 twill
cts�anlyI4W-lsneadat TMALN[.MBERofnsOs
site ddaEs at
cm5MuEaadd2. Yan na c aRll
a'ffiy e>so > adddioaai pages if
e�
4_Tdal sn�dep&t lre3sr7smism.Fare:_ ��U
SQBM WAL Bdt'CR6CI7ON.4
Farnmlrip7evmric7iff��adsxJmJjere+eleami rr~"'m_>t)o'm�d- gIOPi �)
242. Ro3 AI! WeQs ubbmit Elis fam -,iA-m 30 days ofmmlilmao of Hell
30. SlticGaterlanal Via.- top ofeu -?go($,
eao� =lim101hefanocda,-
Ij emrrleMl isabni� ffi -_-
I)Islvmofwh er F
010M?A&MSera
e
(rr, 6 NC27693..2b17
nn n f
IZ Wellanmeead: YCO Tea. /'1 !.X r"I ! e dQ
24b. JE -h inn Wcg= LI adds ion to sig Ere fame tD *0aftm is 24a
aFifis fam Iddda 30 days ofeompldam
above. also Ifo
fie aagq xom(y, mblt dvvtp ac.)
cacEaa �Efe o of wall .
FORWATERSUMM"yti'ETIT ONLY: --,��'
il3si�'�e: W2tetRfsamos, C•ed d�j � j
o
53a Yeld ftm)_
r
563616^sr75asi�Ceoffir, ,27[99-1Q6 .
gid Of test: t
y- )�1
536' tYPz�'
gg 24,- Fer W=kr Surds- do 7n"a�® WeRm ID nddAi m W sending
�camFlea� r��ca�>i� Copy of
30 daysf
o wh epu mt o l days of
vdt c nsaua3eri tet} fit of flee caDary
Fmm GW -1 1,-6C= `{-��a'�IQY+1itp-Didaionof WxtrrRsau¢6
R-kWI-21:2016