Well CompletionHARN "T DEPARTMENT OF PUBLIC HEALTH --RMIT
TO C. _,STRUCT A DRINKING WATER SUPPLI ELL
PIN #: 061249-4726.000 Parcel #: 13 0602 0139 08 Application #: 17-5-40947R Subdivision: River Ridge Lot #: 4B
Applicant Name: Matthew Porter
Address: 103 Mystic Lane Lillineton, NC 27546
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Lot 4B River Ridize Drive
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 stt�ctures and appurtenance) or modification in use of the well, may
subject this Permit to revocation C� jyc �"'� �z� ljlg y�
111r""r5
Authorized State Agen C Date wl - 5--1%
Grouting Inspection I essed Date
❑ 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? ❑ Yes ❑ No
Static Water Level: Top of Casing is _ in. above surface. Yield: _ gpm at ft.
Disinfection: Type Amount
Water Zone (depth)
From To
From To
From To
Casing
From _ To
Diameter: Material:
From _ To
Diameter: Material:
From _ To
Diameter: Material:
Inspector: On Hold Date: Release Date:
Remarks:
Grout
From 0 To
Thickness: Material: _ Method:
From To _
Thickness: Material: Method: _
From To
Thickness: Material: Method:
Well Head Information
Casing Height: 18;n+ above finished grade) �ccess Port: - —t.� Vent Stack:
Well ID Tag: ump ID Tag: J Sampling Tap: ✓� Backflow Preventer:
Sample Taken? es ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Date 1 a/Ol /1-T
Application 4:17-5-40947R
Well Construction Sketch
Applicant me: Matthew Porter Subdivision: River Rid- Lot #: 4B
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