Well CompletionHAR- -TT DEPARTMENT OF PUBLIC HEALTP ',RMIT
TO. _ -jNSTRUCT A DRINKING WATER SUPPL. NELL
PIN #: 0691-01-6254.000 Parcel #: 070691 0151 02 Application #: 17-5-42816 Subdivision: NA Lot #: NA
Applicant Name: SECU RE Inc. (Sam Adams)
Address: 119 N SALISBURY ST RALEIGH. NC 27603
Type of Facility Served by Well: SFD
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Sewage System: Conventional Gravity -Feed Gravel .a,. oALp
Permit Conditions: Location - 44 HILLBILLY LN COATS, NC 27521 -� e g
General Permit Conditions: JOAO �
• Drinking water supply well construction must meet 15A NCAC 02C.100 rules UUU
• 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 Agent [ Date
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ Is
See attachment for construction sketch
Remarks
Well Head Information
Casing Height: (above finished grade) Access Port: w�-- 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
WELL CERTIFICATE OF COMPLETION
Date: Q J;1ol r+ Application #: N -5 -OM2 Well Contractor: �c+z- La�X
Applicant Name:
Address:
, �o I
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 (death)
Casinn
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: (above finished grade) Access Port: w�-- 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
,Applicajion #:17-542816
Well Construction Sketch
Well Completion Sketch
Applicr 'Mame: SECU RE Inc. (Sam Adams)
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