Well CompletionHARNT -DEPARTMENT OF PUBLIC HEALTH f IMIT
TO CG_STRUCT A DRINKING WATER SUPPLY .. ELL
9670 -47--3V52= t73968�i-ioaZ I?l,)--w15_3y
PIN #: Parcel #: _ Application #: _ Subdivision: _ Lot #:
Applicant Name: -nm/n., �2OSs
Address:
Type of Facility Served by Well: 'Simms
Sewage System: Z5C9u rtp_�
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
Authorized State Ag nt /'4_4 i.lf' Date
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -I provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
n
Date: S-IF_n Application #: Well Contractor: 1(ELCP,C�C�/CVCSGL�
Applicant Name:
Address: _
Directions to Site:
Use of Well: _
Static Water Level:
Disinfection: Type
Water Zone (depth)
From _ To _
From _ To _
From To
Inspector: _
Remarks:
Date Drilled: Total Depth: _ Replacement Well? ❑ Yes ❑ No
Top of Casing is in. above surface. Yield: _ gpm at _ ft.
Amount
Casin¢
From _
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 f�pished grade) Access Port: J✓ent Stack:
Well ID Tag: � Puryfp ID Tag: Sampling Tap:/ Backflow Preventer:
Sample Taken? ❑ Yes [� No Well Head properly sealed: /_
Remarks:
Authorized State A �� F t Date
See Attachment for completion sketch
��Jp— kation #: %om�y ty,w"
.4 ation #: Applicant Me: Subdivision:
Well Construction Sketch
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Well Completion Sketch
Lot #:
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