Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
ISII-s�-o�sG �Z`15�7 0/D(, I'1 -S yto7Z
PIN #: Parcel #: _ Application #: _ Subdivision: _ Lot #:
Applicant Name: _22y'C'4
Address:
�.�75/��i>✓f.t../(, �j Duosnl rv.G ZU' 33�p
Type of Facility Served by Well: SFD r'F S �J
Sewage System: ____ 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 A at —Date ' -L /3— 17
Grouting Inspection W essed /-' Date
❑ Grouting self -certified by driller GW -I 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: Date Drilled: —Total Depth: _ Replacement Well? E]Yes ElNo
Static Water Level: _ Top of Casing is _ in, above surface. Yield: _ gpm at _ ft.
Disinfection: Type _ Amount
Water Zone
(depth)
From
To
From
To
From _
To
Casing
From To
Diameter: Material:
From To _
Diameter: Material:
From To _
Diameter: Material:
Inspector: _ On Hold Date: Release Date:
Remarks:
Thickness:
Thickness:
Thickness:
Grout
From 0 To
Material: Method:
From _ To
Material: Method:
From To _
Material: Method:
Well Head Informal'
Casing Height: ove finished grade) Access Port: / Vent Stack: /
Well ID Tag: � Pum Tag: _ Sampling Tap: // Backflow Preventer.
Sample Taken? ❑ Yes No Well Head properly sealed:
Remarks: c�
Authorized State AgDate
See Attachment for comple on
sketch
A�pliion7t� 72' Applicant Name: Subdivision: Lot N:
Well Construction Sketch
Well Completion Sketch
N� Li moi
15" wea.0
WELL CONSTRUCTION RECORD (GW -1)
1. Well Contractor Information:
Derek Lynn Johnson
Well Contractor Name
4363-A
NC Well Contractor Certification Number
Barefoot's Well Drilling & Pump Service LLC
Company Name
2. Well Construction Permit #: 17- 5—WO 7
List al/ applicable well construction permits (i.e. UIC. County, Stare, Variance, etc.)
3. Well Use (check well use):
[3MunicipaVPublic
(HeWing/CDoling Supply) Residential Water Supply (single)
rmmercial ®Residential Water Supply (shared)
Recharge
Groundwater Remediation
Storage and Recovery
Salinity Barrier
Test
E3Stmmwater Drainage
cental Technology
Subsidence Control
mal (Closed Loop)
Tracer
4. Date Well(s) Completed: Well ED#
5a. Well Location:/ p
Facil /Owner Name Facility ID#(if applicable)
331-5 Irl-Aiut)(C k Rd i7unn !)!- 2Ri3�
Physical Address, City, and Zip
4i,-Ae 1- 151727-073&
County Parcel Identification No. (PIN)
For Internal Use Only:
14. WATER ZONES
TO
DESCRIPTION
MDFROM
R- rt•
FCG7�
ft. ft.
15 OUTER CASING for multi -cased wells OR LWJFROM
TODIAMETER
THIE.g
r fn. 616.
INNER CASING OR TUBING eotM1ermaI elFROM
TO
DIAMETER TH
R. ft.
in.
iL ft.
17. SCREEN
in.
FROM TO I
DIAMETER I SLOT SUE THICKNESS MATERIAL
R. fL
in.
18. GROUT
FROM I TO
MATERIALEMPLACEMENT METHOD &AMOUNT
O ft. 30 It.
S\6te I r r
n. R.
ft. re.
19. SAND/GRAVELLPACK ,(if applicable)
FROM TO
MATERIAL I EMPLACEMENTMETHOD
ft. R.
ft. I ft.
20. DRILLING LOG (attach edditionalsbeetsifnecessa
mom TO
I DESCRIPTION coon aardnea, roiVrock qM grain size, etc.
ft. R.
R. rt.
ft. ft.
ft. ft.
ft. ft.
rt. ft.
tt. ft.
21. REMARKS
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latnong is sufficient) 22. Certif ation:
353 ES N 6�'1 !2o W
q-�5i7
6. Is(are) the well(a) Permanent orTemporary a re ofCerji ed Well Contractor pate
By signing this form, I hereby ceH6 that the well(s) was (were) coattructed in accordance
7. Is this a repair to an existing well: ®Yes or : No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair, fill oar known well construction information and explain the nature ofthe copy ofthis recnrdhas been provided to the well owner.
repair under N21 remarks section or on the back ofthisform.
23. Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, only I GW -1 is needed. Indicate TOTAL. NUMBER of wells construction details. You may also attach additional pages if necessary.
9. Total well depth below land surface: 970 (R,)
For mulnp/e wells fist all depths tfdWerent (evample- 3@200' and 2@100)
10. Static water level below top of casing: (R,)
lfwater level is above casing use ..+"
11. Borehole diameter: 6 _(in.)
12. Well construction method: roll /
(i.e+ auger, rotary, cable, direct push, etc.)
SUBMITTAL INSTRUCTION
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) V Method of test: t % 24c. For Water Suooly & Iniection Wells: In addition to sending the form to
p (.� [he address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: f{ L&—) _ AAmount: t -� ���i completion of well construction to the county health department of the county
where constructed.
Form GW -1 North Carolina Department of Environmental Quality- Division of Water Resources Revised 2-22-2016