Well CompletionHARNFTT DEPARTMENT OF PUBLIC HEALTH PrvMIT
TOC( TRUCT A DRINKING WATER SUPPLY( :LL
PIN #: 1528-64-2716.000 Parcel #: 021526 0470 Application #: 17-5-42671 Subdivision: Lot #: Paz #1
Applicant Name: Ken Dawson Homes, Inc
Address: 120 Edmondson Drive Willow Springs NC 27592
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Bryan McLamb Lane (US 301 N )
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 Bent V'w Date //- /7 -/7
Grouting Inspection Vaessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date:041X011$ Application #: 11-6,(4Qf
aWell Contractor: i."Ce
Applicant Name: GAIN U.Lco5 16AO mjrs , inc- .
G,w
Address:
Directions to Site:
Use of Well: _
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes ❑ No
Static Water Level:
_ Top of Casing is
in. above surface. Yield: _ gpm at _ ft.
Disinfection: Type
Amount
Water Zone (depth)
Casing
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 /
Casing Height: -LI-- (above finished grade Access Port: ✓ Vent Stack: _
Well ID Tag:/ Pum Tag: Sampling Tap/ Backflow Preventer: _
Sample Taken? ❑ Yes No Well Head properly sealed:
Remarks: ttOLilijAo'- i,PzQdb-& wairu 6%c ele_ r oPef ijf60.6 e�
Authorized State Agent I/ ��«�. / Date X119 ) a0te
See Attachment for completion sketch
Application #:17-5-42671 Applicant Name: Ken Dawson Homes, Inc Subdivision: Lot #: Par #1
Well Construction Sketch
Well Completion Sketch
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WELL CONSTRUCTION RECORD (GW -1)
1. W I Comrsetor information:
arty �.t/IIIIot-c� 1 r�
Well Connector Nam
tigno3 p -
NC Well Contractor Ccmfipsoon Nitrides
LU i 11r U s We 11 Dr; I A C,
Company Nome
2. Well Construction Permit
List all applicable well construcrtonpermlis (l.e. UIC, County, hate, VaHonce eic.)
3. Well Use (check well use):
vnicipal/Public
(Heating/Cooling Supply) c"ciantial Water Supply (single)
Jmmupisl Residential Water Supply (shared)
Recharge
❑Groundwater Remedistion
Storage and Recovery
13SaliniryBarrier
Test
OIStoxmwater Drainage
,ental Technology
OSubsidence Control
Dal(Cluaed Loop)
OTracu
d. Dau Weill Completed: 71 O Well lD#
Sa. Well Location:
14n Dawson 11orIsS
Facility Mrs Of applicable)
a 5 3n ) Wo V, -kA
city, and Zip
e44- ► sag -4 Y a'71b
County / parcel Identification No. TTN)
Sb. LAtude and longitude In degrees/minutes/seconds or decimal degrees:
(ifdell field, one las/long is sufficient)
35� alt 3t� I N 3 y b o W
6. is(are) the well(a) ermenepr ar oTemporary
7. Is this a repair to an existing well: QYes or No
If this Is o repair, fill out known well mnsiroeoun ulfarmorion ed explain the nature of she
repair under 42) rrmarks sccdon or an the back ufthis)tvm.
8. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
consnuction, only 1 GW -I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: -31 (ft.)
For muLiple wells list all depths afdperenr (--oialr. 3(4200�a/nd 2(Voo')
10. Static water level below nap of casing:
If>,nrer level is above casiry;, use,
11. Borehole diameter:
12. Well construction method: / I 1 �rA �U /U ✓ /
(i.e. auger, rotary, cable, direct push, cm.)
For Internal Us Only
N. WATER ZONE
UlvI ion of WPI
FOR WATER SUPPLY WELLS ONLY:
FRO TO
1636
DESCRIP010N
n.
n h r V�
R.
0.
-
1�,
131). Disinfection type: Th Amount: ` L�2
15. OUTER CABIN
for mulU<aaed wc1b OR LINER Ifo Uwble
PRO TO
DfAMET. THICKNESS MATCRLU.
ft.
ft.
in. V PVC
16. INNER CABIN
ORTUBINC eoWrmal claaddtoo
F0.0M TO
DUMETER THICKNE36 I MATERIAL
In.
17. SCREEN
FROM TO
DIAMETER SLOT S[2E THICKNESS MATERIAL
ft.
in.
10, GROUT
To
MArasrmt,
«.
n liter YA v i
n
H.
n.
D 3 d k
19. SAND/GRAVE
ACK(if a arable
FROM TO
MAEAIAL EMPLACEMEN METHOD
��ft
ft.
n.
20. DRILLING LOC foaft..1t
additional shcete if necesaa
PROM TO
mosCRIFTION eebr, heNeeets tedinea r Irtn Ilea ale.
o ft.
n,
a
n.
«.
`r / h n
re.
rt.
t.
v
ft.
fe.
ft.
ft.
ft,
ft.
SL REMARKS
ZZ. Certification: r
_ /i I r
ys /Ir
Date
By signing Zhu form, Ijryereby carufy that Mur .11(s)+van 6.,e) conservemd in accordance
With 13. NCAC 02C. 00 ur ISA NCAC OX .6160 Well Co,untstlon Standards and that a
copy q/Ihl,. record Aas w, provided at she well owner.
23. Site diagram orleddItional well details:
You may use the b of this page to provide additional well site deuil5 or well
construction details. JYou may also anacb additional pages if necessary.
24a. For All Well
constmetlon to the
Division
1617
24b. For Inieedon
above, also submit
construction to the I
Force GW -I North Carolina Department afShvtronmental Quality -Division
Submit this form within 30 days of completion of well
Ater Resources, Information Processing Unit,
I Service Center, Raleigh, NC 27699-1617
13: In addition to sending the form to the address in 141
copy of this form within 30 days of completion of well
Resources, Underground Injection Control Program,
all Service Center, Raleigh, NC 17699-1636
10 tit IW.,,dou Wella: Lt addition w sending the form to
also Submit one copy of this form within 30 days of
instruction to the county health department of the county
tier Resources Revised 2.22-2016
UlvI ion of WPI
FOR WATER SUPPLY WELLS ONLY:
1636
13a. Yield (Spm) 0 Method or test: 12 M me
Ye. For Water St
-
1�,
131). Disinfection type: Th Amount: ` L�2
the addreas(es) Ab,
completion of well
where constructed,
Force GW -I North Carolina Department afShvtronmental Quality -Division
Submit this form within 30 days of completion of well
Ater Resources, Information Processing Unit,
I Service Center, Raleigh, NC 27699-1617
13: In addition to sending the form to the address in 141
copy of this form within 30 days of completion of well
Resources, Underground Injection Control Program,
all Service Center, Raleigh, NC 17699-1636
10 tit IW.,,dou Wella: Lt addition w sending the form to
also Submit one copy of this form within 30 days of
instruction to the county health department of the county
tier Resources Revised 2.22-2016