Well CompletionHARNF^T DEPARTMENT OF PUBLIC HEALTH {" 'MIT
TO CC TRUCT A DRINKING WATER SUPPLY . ALL
PIN #: 0598-88-8901.000 Parcel #: 071508 0046 04 Application #:17-5-42686 Subdivision: Fred Turlington
Applicant Name: Mark Craft (Greenfield Housing)
Address: 2117 Hwy70 East Gamer NC 27529
Type of Facility Served by Well: Single Family Modular
Sewage System: Accepted System
Permit Conditions:
Lot #: 5
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 ALTE of the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this PerriliLto rem t&jn,_
Authorized State Ag �.� Date 1 t 1 7 1
Grouting Inspection Zessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: t73IWI19j Application #:IT-5-yXIEVell Contractor: goh^ J (k ms 3r
Applicant Name: �c nvxx a C was
Address: a IS P�cf�< cr ccv. rz ,
Directions to Site:
Qxg'esfl GU> - I t CX
Use of Well: —Date
Static Water Level:
Drilled:
Total Depth: Replacement Well? ❑ Yes
❑ No
Disinfection: Type _
Top of Casing is
Amount
_ in. above surface. Yield: _ gpm at
Water Zone (depth)
Casing
From _ To
From To
Grout
_
From _ To _
_
Diameter: _
From 0 To
Material: _ Thickness: Material:
_
From _ To _
From _ To
_ From
_Method: _
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: _�
ump ID Tag: /
Sampling Tap: / Backflow Preventer:
Sample Taken? es
[3 No Well Head properly sealed:
Remarks: —
Authorized State A ent
g
lam—��
i ��t�Date_
_
�3/0Gf18
See Attachment for completion sketch
Application #: Applicant Name: S, 'ivision: Lot #: 5
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Well Construction Sketch N o VbNn�)
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Well Completion Sketch
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