Well CompletionHARN- "T DEPARTMENT OF PUBLIC HEALTH" RMIT
TO C`..STRUCT A DRINKING WATER SUPPLl .JELL
PIN #: 1515-09-5589.000 Parcel #: 021505006601
Applicant Name: Red Door Homes
Address: 142 Shenstone Blvd Gamer, NC 27529
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Application #: 17-5-41700 Subdivision: Lot #:
Permit Conditions: Location: Chicken Farm Rd. / Dunn-Baersville Rd. (SR 1790)
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 revocations
Authorized State A nt v Date
77
Grouting Inspection Witnessed 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:
Static Water Leve_l:
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
Amount
Casing
Grout
From To
_
From 0 To
_
Diameter:
Material: _
Thickness:
Material:
_ Method:
From _ To
From
To _
Diameter:
Material: _
Thickness:
Material:
_ Method:
From —To
_
From
To _
Diameter:
Material:
Thickness:
Material:
Method:
On Hold Date:
Release Date:
Well Head Information
Casing Height: , (above finished grade) _Access Port: Vent Stack:
Well ID Tag: ump ID Tag: ✓_� Sampling Tap: Backflow Preventer:
Sample Taken? es ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Application #:17-5-41700
Well Construction Sketch
Applicant T * ne: Red Door Homes Subdivision: ' of #:
Well Completion Sketch
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Well Completion Sketch
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