Well CompletionHARN7 "DEPARTMENT OF PUBLIC HEALTH P"T MIT
TO CG,.STRUCT A DRINKING WATER SUPPLI r,LL
PIN #: 0596-97-4735.000 Parcel #: 06 1506 0063 01 Application #: 17-541987 Subdivision: Lot #:
Applicant Name: Joseph Bain
Address: 3833 Rusty Rail Rd. Fayetteville NC. 28312
Type of Facility Served by Well: SFD
Sewage System: 24% Reduction System
Permit Conditions: Warren Road (SR 1741)
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 inc ding location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State A nt Date
Grouting Inspection W essed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: W/(,*a Application #:171-5-y/`1iMell Contractor:
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 ft.
Amount
Casine
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: 4"q ove finished grade) /.Access Port: ✓ Vent Stack:
Well ID Tag: Height:
ID Tag: J Sampling Tap: �— Backflow Preventer: ✓—
Sample Taken? es ❑ No Well Head properly sealed: ✓
Remarks: _
Authorized State Agent 'c�� Date
See Attachment for completion sketch
Application #:17-5-41987
Well Construction Sketch
Applicant; ie: Joseph Bain Subdivision: ',ot #:
PUMP To fL�P4m-
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Well Completion Sketch
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