Well CompletionHART 'T DEPARTMENT OF PUBLIC HEALTH 'RMIT
TO( .1STRUCT A DRINKING WATER SUPPL. FELL
pfl 3 -bS-�f1.92°°d 14-5' 3'filLS
PIN #: Parcel #: �ZY"nkpplication #: _ Subdivision: — Lot #: Z
Applicant Name: ,ALG.
Address: _Z& J /HAST r 1.
Cr
t2Ater N• �• 2"7(oos
Type of Facility Served by Well: SFD
Sewage System: -2,M ()�D
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 n 4
Authorized State' ent �Datte�"g�-Q-/G
Gro g Inspection W sed Date 05 yl /
Grouting self -certified by driller Gd? e
W -I provides E-1No
See attachment for construction sketch
,f.-
6 $' S`/ 3 WELL CERTIFICATE OF COMPLETION
Date: /11 Application #:�—Well Contractor: - R,AIASO o
Applicant Name: Iv •L• Corral , t. L C
Address: 3209 ,.toast /Z cl - 2.,14-�Iti
Directions to Site: _
Use of Well: (19514'41 Date Drilled: 63O I I1-- Total Depth: �,b�5•S� Replacement Well? ❑ Yes C/No
Static Water Level: 2nG�, Top of Casing is _ in. above surface. Yield: -4-- gpm at _ ft.
Disinfection: Type Amount
Water Zonede
th
To \t �,
Ca ina
U a From \_5v
To 43A-' ('
Grout
1-0
From \ 1 t1 G!
From 1 L\
To titiGG
Or Diameter: Uj' Material: ion\J Thickness: \b�
From 0 To
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: 1 Z t n(above finished grade) Access Port: Vent Stack: r/
Well ID Tag: Pump ID Tag: Sampling Tap: �� Backflow Preventer:
Sample Taken? es ❑ No Well Head properly sealed:
Remarks:
Authorized State A n
See Attachment for completion sketch': �/%s
Application #: Applicant Name: Subdivision:
Well Construction Sketch
jSlope
Lot #: Z
Well Completion Sketch
N ~ }
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v
j TO flin�IocK
y �z,
naf. 3. 2011, 1:
rrfh►JL wlr�inuL1 IuQN1dCM
Thn form au, Le mad no' $male mrmu6pre'aIle
A. NVOI Contractor 1"Fermntlon:
&' �. t iMDson
Wdl em,a.c,arrvam. nn --
�S � 7T
NC Well Conwactor CtNBcaden Numb,
N.W. Poole Well & Pump Co.
Cmppsny Name
7.. Well Construction Permit k:
Llsr all appllra6/a wv/y ronnnmrio,y, —
,Is (I. e. Cowry, S Nlfpalf -' 11C)
3. well Use (check well use):
No. 5143 P. 1
For latcrpel Bac oNLAI-5- 3g3Y3
m I fc
DAgricultural
OMwicipal/Public
0, re
CGcolhcrosal (Heating/Cooling Supply)
Olndustrlal/Commcrelal
01111 ation
Non -Water Supply Well:
'Atesidentiel Water Supply (single)
ORasidenual Water Supply (shared)
It, ft.
To
is. it,
❑MOn(loring
Iujecfion Well:
❑Aquifer Recharge
CAquifer Storage and Racovcry
OAquifer Tes[a
❑Expenmentel Technologym
DRecuvcry
OGraundwater Remediation
CSalinity Bonier
05loanweter Drainage
OSuhsideneo Control
a• n.
IL It
FlWM 0
R.
m
1)0cWhorrial(Closed Loop)
OTreccr
4, Dale Wtll(6) Completed: J
3. Well Location+
padlily/Owner Namo 1p� 1 Facility MA(ifspp6uhlo)
1 h�
Physical Address, Cei-ry},'arynd Zip
�S�`
CO°nd Porcel Ideati&edoa Na. (pM)
3b. Latitude sad Longitude in degr<m/ninnies/aecopde or decimal degrees: �—
(if weg Gald, one IaVleog is sui6cient) 22. Certification!
Z4 N - • �g3oS4 W
U. Is (arc)ibe well(s): crmeneot or Mortarsry grgoanue ofCetu6ed wcu C000-eavr Dae )
In.
Oftl �-)- m1 vc oar
'/. Is thls a repair to an assisting well: OYes or p
("his Ir a repair, fill curk'owe wall eorupuelion Iri(prmoilan and uplaln he May,v%rNr
repair Wider 071 remarks secaon or on rhe baekof d4 form.
3. Number of weUs constructed: tl
6or muluple m/emmn ar non -wars, supply walla 0jVfwbN the rear emanation, you tun
mbmbmafarm
9. Total Wall depth below land surface:_�J„ (rc)
rot wnlr/tris o•elld /UI all deerhs 0101fem (¢sample- JoaVVV'and2®100')
Q. Static water level below top of casing: �-J•-t.!
I �"ate, level Is oboue rosbrg, use "+" (R')
U. Borehole diameter:
12• Well construction .,(bad:
(i.e. auger, tolary, cable, i ireet pub, etc)
By atgntng this form, 1 hereby cgf% lhay Ike we11(.r) ass (1-1m) canslracad ,or eccm'danee
wnb 154 NCAC 02C .0100 ar ISA NCAC 02C.0200 Well Conslrocnon Srondardr and Umr o
COPY oflluf reeordhor been pmulded to rhe waif owner.
23. Slit diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
construction details., You may also attach additional pages if necessary.
24. Submittal Instructions:
24a. Far_AU Well,: Submit this form within 3o days of completion of well
construction to the following,
Division of Wafer Qaalily, Information Procewiag Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
241y, For Infection Wena:.In addition to sending the form to the address in 24a
above, also submit a copy of this form Within 30 day, of compieti,, of well
construction to the following:
)3. FOR WATER SUPPLY WELLSONLY: Division of Water Quality, 0adergrouad IafecUon Caamol Program,
(r� 1636 Mail Service Center, Raleigh, NC 27699.1636
I no, Yield (gpin) �_ Metbod of feat: \�� 24Q For Waap
ter Spiy & C nth I Wells: In addition to sending the form to
the address(es) above, also submit one co of this form within 30 days of
'3b. Disinfection type: T1 �' � Amount: _L10 _ completion of Well construction to the county health department of the cowry
E
where coflsWe[od.
Bonn GW -1 N°rtb Carolina Department ofEavirmixectit and Nam[ Roseureas- Diwion ofwaarali
Qa h Rcviesdlus. 2013
1 ♦
♦
L�
•
'/. Is thls a repair to an assisting well: OYes or p
("his Ir a repair, fill curk'owe wall eorupuelion Iri(prmoilan and uplaln he May,v%rNr
repair Wider 071 remarks secaon or on rhe baekof d4 form.
3. Number of weUs constructed: tl
6or muluple m/emmn ar non -wars, supply walla 0jVfwbN the rear emanation, you tun
mbmbmafarm
9. Total Wall depth below land surface:_�J„ (rc)
rot wnlr/tris o•elld /UI all deerhs 0101fem (¢sample- JoaVVV'and2®100')
Q. Static water level below top of casing: �-J•-t.!
I �"ate, level Is oboue rosbrg, use "+" (R')
U. Borehole diameter:
12• Well construction .,(bad:
(i.e. auger, tolary, cable, i ireet pub, etc)
By atgntng this form, 1 hereby cgf% lhay Ike we11(.r) ass (1-1m) canslracad ,or eccm'danee
wnb 154 NCAC 02C .0100 ar ISA NCAC 02C.0200 Well Conslrocnon Srondardr and Umr o
COPY oflluf reeordhor been pmulded to rhe waif owner.
23. Slit diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
construction details., You may also attach additional pages if necessary.
24. Submittal Instructions:
24a. Far_AU Well,: Submit this form within 3o days of completion of well
construction to the following,
Division of Wafer Qaalily, Information Procewiag Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
241y, For Infection Wena:.In addition to sending the form to the address in 24a
above, also submit a copy of this form Within 30 day, of compieti,, of well
construction to the following:
)3. FOR WATER SUPPLY WELLSONLY: Division of Water Quality, 0adergrouad IafecUon Caamol Program,
(r� 1636 Mail Service Center, Raleigh, NC 27699.1636
I no, Yield (gpin) �_ Metbod of feat: \�� 24Q For Waap
ter Spiy & C nth I Wells: In addition to sending the form to
the address(es) above, also submit one co of this form within 30 days of
'3b. Disinfection type: T1 �' � Amount: _L10 _ completion of Well construction to the county health department of the cowry
E
where coflsWe[od.
Bonn GW -1 N°rtb Carolina Department ofEavirmixectit and Nam[ Roseureas- Diwion ofwaarali
Qa h Rcviesdlus. 2013