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Well Completion
HARNI - T DEPARTMENT OF PUBLIC HEALTH P- .MIT TO Cl iTRUCT A DRINKING WATER SUPPLY LLL PIN #: 1600 26 1747.000 Parcel #: 0716000262 Applicant Name: Signature Home Builders. Inc Address: 1209 N. Main St. Lillineton, NC 27546 Type of Facility Served by Well: SFD Sewage System: 25% Reduction System Permit Conditions: Ebenezer Church Road (SR 1558) Application #: 17-5-4166 Subdivision: , MVV Lot #: 2 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 revocatio AuthorizedState(Aaent -7—_4- Grouting Inspection WStr(ssed Date ❑ Grouting self -certified by driller GW -I provided? ElYes ❑ N_o See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: 12JRolf4 Application #: Contractor: "au1+�, 1 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 fl. Amount Casine 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: Jq,,,c (above finished grade) Access Port: Vent Stack: Well ID Tag: PumpID-T-g: sampling Tap: Backflow Preventer: _ Sample Taken? ❑ Yes ©'No Well Head properly sealed: ✓ Remarks: 1> -),LC— 4�rryt-e_ Authorized State See Attachment for completion sketch A//G G Application #:17-i-41�tj5 `� Applicant Name: Signature Home Builders, Inc Subdivision: Lot #: 2 Well Construction Sketch Well Completion Sketch fP e :VfuAC (N1cRi`.iDI I AmrA I zl of Vu vu� n Q1451.-O `4i N m a IY r a c� J ♦I� J � 1, ;♦ Well Completion Sketch G PJE�3b Zr'=tt- L� V2Ge1- 2p SrL_ sSS� fP e zl of n G PJE�3b Zr'=tt- L� V2Ge1- 2p SrL_ sSS�