Well CompletionHARP'_T DEPARTMENT OF PUBLIC HEALTB "'.RMIT
TO( -JSTRUCT A DRINKING WATER SUPPL _ ✓ELL
PIN #: 9599 02 1119.000 Parcel #: 039589 0152 04 Application #: 17-5-41135 Subdivision: NA Lot #: NA
Applicant Name: Brad D. Cummings
Address: 3001 Bella Bridge Rd Broadway NC
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
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
Grouti nspection WiKessedL
LJ,Grouting self -certified by driller
See attachment for construction sketch
Date V-2 $-f7
-Date
❑ No
WELL CERTIFICATE OF COMPLETION
Date: oyhyIll Application #: 116 -Mit Well Contractor: acs 7o cYSon
Applicant Name: Fri C.,,.+ iA
Address: 3wi c%2. /3ro,,A�y
Directions to Site:
aae r�'e (m W -t--r�d_�-
Use of Well:
Date Drilled:
Total Depth:
_ Replacement Well? ElYes
❑ No
Static Water Level:
Top of Casing is
_ in. above
surface. Yield:
_ gpm at _ ft.
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: W �_ (above finished grade) Access Port: ✓ Vent Stack: _f
Well ID Tag: Pum ag: Sampling Tap: f Backflow Preventer: -�
Sample Taken? ❑Yes o Well Head properly sealed: .�
Remarks:
Authorized State Agent '3' Date It'a4(acvl47--
See Attachment for completion sketch
Application #:17-5-41135
Well Construction Sketch
Applican' "ame: Brad D. Cummings Subdivision: " �, Lot #: NA
Well Completion Sketch
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