Well CompletionHARN- -T DEPARTMENT OF PUBLIC HEALTH,r RMIT
TO Ck ..STRUCT A DRINKING WATER SUPPL] ELL
PIN #: 0517-98-7420.000 Parcel#: 1305270020
Applicant Name: Christina Jardine
Address: 2317 Park Summit Blvd Apex, NC 27523
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Application #: 17-5-41438 Subdivision: _ Lot #:
Permit Conditions: 324 Clark Rd. (SR 1129) - Reference Construction Sketch
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 (inc location of
ctures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State ent 4 /'( Q Date 4-2-17
Gro gInspection tnessed ate 01-1/-/
LO"brouting self -certified by driller GW -I provided? es ❑ 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? El Yes
El No
Static Water Level:
_ Top of Casing is
in. above
surface. Yield:
gpm at
Disinfection:
Type _
Amount
Water Zone
(depth)
Casing
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: 1 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:
Remarks:
Authorized State
See Attachment for completion sketch
Application #:17-5-41438 Applicant ",me: Christina Jardine Subdivision: tot #:
Well Construction Sketch
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WELL CONSTRUCTION RECORD
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OOcaMr'ml(}f OOI®R SuR40 OR9fidmUd Watu SuV*-(,it*)
om•r-..:.rr��I ORS Wale Supply (56Rcd)
GCaormdnarcr Rmrcdiation
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21 Site diagram wedd:ti...a At dcnRs
You may r the back of this pays to prmidc add . wdt sore dctaas w wd1
comvuctlun d®ils. You nmy abo arlxh ad34aral yaps if acc®y
SUBMFIT4L INSR)CnONS
24a. For AO Wella Submit this form wdbia 30 days of wmplelpp of well
oortsrr -bm b fhc&Ilowin¢
13iyoian ofwaNtr Rceertg iobDrmtino Pttremcbog UK
1617 MaR Savior Cater. Rab kk NC 276W,617
24h. For lgkgilr. 1Ydk QU.Yc In addition to saWine the thrrrr to Uro addnss in
240 abrnK also submit a wpy of this form P-ithi, 30 da)s of amlq)klian of uell
coastructa Io tltr following:
=DWaftctios
Y WELLS ONLY: Dieisim ofWattr Resawrt Uuderg,waad IajttSon Central Prognm,
1636 Marl Scvkc Cmter. Raleigh, NC27699-1636
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