Well CompletionHARNE—T DEPARTMENT OF PUBLIC HEALTH Pr'^MIT
TO CC TRUCT A DRINKING WATER SUPPLY LL
aft ' x-irm O �ua.Ju3Gt*�-1�
PIN #: Parcel #: Application #: Subdivision: _ Lot #:
Applicant Name: -�2��.�ae,�ttuCs
Address: N--5^
5 ` to tt e'4 Lf
Type of Facility Served by Well: SFD
Sewage System: —26% /tom : y }
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
Grouting Inspect!
❑ Grouting self-(
See attachment for construction sketch
U W A provided'!
Date
❑ No
WELL CERTIFICATE OF COMPLETION
I t�S
Date:' 141 Application #:3T3toa Well Contractor: 1"q j4e i /V�S
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)
Casine
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: Vent Stack: _
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Ag t/'/!j7✓� Date
See Attachment for comp
(6 S' 34310 , .h
/por�.�C��
Appbca[ion #: Applicant Name: Subdivision: _i/ce Lot #:
Well Construction Sketch
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