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Well CompletionHARNPTT DEPARTMENT OF PUBLIC HEALTH PERMIT TO C 3TRUCT A DRINKING WATER SUPPLI ELL PIN #: 1518-77-1077.000 Parcel #: 021517 0405 01 Application #: 17-5-42650 Subdivision: Applicant Name: James Jackson: Lone N McLean Address: 436 Oak Valley Farm Road Coats, NC 27521 Type of Facility Served by Well: SFD Sewage System: 25% Reduction System Permit Conditions: Location - Brookleaf Drive (Faireround Rd - SR 1705) Lot #: 113 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 Statement nAia -J1- Grouting Inspection Witnessed Date _ ❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date:0.3/a)'tf3 Application #: 17-5-t4WWell Contractor: t-``rri w-,Wk�.L Applicant Name: TW4&a , T� xsoo Address: Ix -4v- *,:6 41aj. 5el'-' GW -1 -'t ri Directions to Site: Use of Well: Date Drilled: Total Depth: Replacement Well? ElYes ❑ No Static Water Level: Top of Casing is _ in. above surface. Yield: _ gpm at _ ft. Disinfection: Type _ Amount Water Zone (depth) Casin¢ 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 % j Casing Height: above finished grade) / Access Port: ✓ /Vent Stack: Well ID Tag: P�u9P ID Tag: ✓ Sampling Tap: ✓ / Backflow Preventer: _ Sample Taken? El Yes [2No Well Head properly sealed: Remarks: �-rn 1e- -6 \eo- J'J:� — k2r'.qtr"...,este -d- i � j -t ,'t .r) 63 l Qt l lg h12- Authorized State Agen �6��� / �` Date �3 aU% aU1p3 See Attachment for completion sketch Application #:17-5-42650 Applicant TJame: James Jackson Subdivision: _ Lot #: 1B Well Construction Sketch .J2 OU Vk�- Well Completion Sketch SJITIA-L 5;•qT7C- .har..sr a61- 5� 136111 / Q5� i w� 1. Well Contractor Information: j- arra wl`1ify��ji� WellConmctorNarae a�63 -Ar NC Well Contractor Certification Number JAI I S Company Naote Ff''SI '� jj �1 )) 2. Well Construction Permit #: )- j - 5 .- -t a t� 5 ©/ - 5 �l d tD S List all applicable writ co, oovcdon permits C..c. UIC Conray. State, slanaace, eta) 3. Well Use (check well use): OMmicipal/Public (HeatingtCooling Supply)esidential Water Supply (single) omrnescial Residential Water Supply (shared) Well: Recharge ®Groundwater Remediation Storage and Recovery QSalinity Barrier Test OSmrmwater Drainage ental Technology QlSubsidence Contml not (Closed Loop) Tracer nal(Heatinwr=line Return)rlOther(emlainundcr#211 I— V. 4. Date Well(s) Completed: d -v 1- l O WdI ID# Sa. Well Location: Long rnc1-p4n1 Facilf�tylOwacr Name Facility [DO (if applicable) -qq� Qi -a* eet F 12r; VC bid P�h�y`'nl Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrces/minuteslseconds or decimal degrees: (ifwell field, one lar/bng is sufficient) 35'9al - 73y' N 7g" 144 W 6.ls(are) the well(s) V171nanent or ❑ITemporary 7. Is this a repair to an existing well: [lYes or mNo Ifthis re a repair, fill oat known waft canstmctian hrformaWn and esplain the eamrc ofthe repair ander #21 remarb rection or on the back oftbis farm. 8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same construction, only 1 GW -1 is needed. indicate TOTAL NUMBER of wells 9. Total well depth below land surface: a u (ft.) Par multiple wens list all depths ifdif(ereea (emmple- 3@200'..d 2@1001 10. Static water level below top of using: (ft) Ifiwte level fs &bone caring, use "t" 11. Borehole diameter: 6t (in.) /y 12. Well construction method: t r L c4 d r G Tar Y (i.e. Muga, rotary, cable, direct push, etc.) a y % a�it i cocty-se is, Ad ft f. 15. OUTER CASING for multi -cared wdh OR LINER f M iuhl0 FROM TO DGMEfER TInCKNFSS MATERIAL I— V. 11 IL in. I 5GH IN 16. INNER CASING OR TUBING( rothernmleloscddoo FROM, I TO DIAMETER TmC ESS I MATERW, ft fL ta. ft. R in 17. SCREEN FR TO DIAMETER I SLOTSI]8 I TR1C5K�Nf5g MATEmAL io. a (,,19-15( (/ p fL ft. 10. GROUT FROM TO MATERIAL EMPLACEMENTMEIHOD&AMOUNT a uD• 6ewhirti Jur, c xvi ft. M © Sv b u 19. SAND/GRAVEL PACK ifa Eee61e FROM TO MATF2nAL FMPWCEMENTMRTROD ©ft 1L SR ti' V u r irdl v f' ft ft. 20. DRILLING LAG (attach additional sheon if accon FROM TO DESCRIPTION a r. hmasess, mi0rock Wa, gratasxv ate D ftS- n. «. $'a nG G lay fZ IL f&jn G u a LT (L R 'su n ft. It. & & ft. R 22. Cerdro adon: Signature of Ce&fled Well Con or Data By signing Itis fort I hereby ce rfifi that the we//(e) was (were) eawoveled M accordance with 15ANCAC 02C.0100 ar 15A NCAC 02C.0200 Well Cvnstnuabn Standard& aad Char a copy it' this record has been pro vided1. the .11 ~w ,.. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTRUCTIONS 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 Infection Wells: In addition to sending We four to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, FOR WATER SUPPLY i` �WELLS ONLY: 1636 Mall Service Center, Raleigh, NC 27699-1636 13a. Yield (gpm) Method of test: U M )19 n C 24c. For Water Supply & Infection Wells: in addition to sending the form to fr- the addraas(es) above, also submit one copy of this form within 30 days of 136. Disinfection type: Amount: completion of well construction to the county health department of the county ornate constructed. Form GW -1 North Carolina Department ofEnvironmotal Quality - Division of Water Resources Revised 2-22.2016