Well CompletionHARNFTT DEPARTMENT OF PUBLIC HEALTHr ZMIT
TO 0;TRUCT A DRINKING WATER SUPPLY ELL
PIN #: 0663-90-8150.000 Parcel #: 040673 0121 12 Application #: 18-5-43039 Subdivision: Adams Farm Lot #: 3B
Applicant Name: Karen Wood & Robin Cooper
Address: 1000 Tvler Farms Drive Raleigh NC 27603
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions: Millwood Lane (Hwy 201 N) - Adams Farm S/D Lot 3B
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 Agent Date aa' oq I (Q�
Grouting Inspection Witnesse Date CA4 I VG I Fd
ElGrouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 05130 t8 Application #:18-5-43039 Well Contractor: 'S 2Ln owe
Applicant Name: V4�en �-b«x'� i a�6tri Cm,kr
Address: _
Directions to Site:
Use of Well:
_
Date Drilled: _
Total Depth:
_ Replacement Well? ❑ Yes
E] 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:
_
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 Ta
Sample Taken? es [I No Well Head properly sealed:
s Backflow Preventer. ��
Remarks: - ''
Authorized State Agent Date
See Attachment for completion sketch
Application #:18-5-43039
Well Construction Sketch
Applicant °Lame: Karen Wood & Robin Cooper Subdi«` ion: Adams Farm Lot #: 3B
Well Completion Sketch
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May.09.2016 09:47 Grady Poole Well Drilling 9192660188
PAGE. l/ 1
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'1'Ids Poen out be need for single or multiple wane
1. Well Contractor lnformAllow
Jason Poole
1'or lulenml Uxo (7NLY;
Id. WATER WINKS
Well Contractor Noma
2279-A
NII Well Cotonou)Ceuifrootimt Nonlbn.
Grady Poole Well & Pump Co Inc
0 n• 01
n. (I.
IS. OUTERCASING for malibcasW wdb nRLINEK If• dira6le
MOFI 1'UI
DIAms"ran 'I HICKNYAa MATFAIAI.
0 D' n e 11
Company Name
2. Well Construction Perinlf It:
U,1'IOII (l11,111Y41v iodt/krlrlOf (LU. Cglnly. All. Pinter...T. Int,"hrn, x/e)
3. Well Use (cheek well use):
16. INNFM(:ASINrr(INK 'fDDING tive.lbrinuid elwed-los
fllOnl'rel
IIIAMKI'KN THICKNTAS MATERIAI,
K. n. In.
17. SCREEN
Wolter Supply Well:
anyric0tural
OUcolhcrnml (Idcutin Colin SunpIr)
oh,dusulm/Conuncmial
❑Irri lion
CJMunicipai/Mtblic
FRcsidentiul Water Supply (sinlo)
011osidentiul Water Supply(shured)
FROM
III
IIIAMFTCA 81AR 91%K 7LII:KN" 810L1'KMIAL
n•
n
In.
n
!t
I&GROUT
MOMT/r FIATERIAL
F: rI.AOKMr..Nr MKrl!Oi1 &AMOUM'
0 D. 20 fl.
Portland &
Gravil
Non -Water Supply Well:
OMonituring
ORecovcry
o. D.
Screenings
sncreeni
hdcCltou Well:
OAr)ai(cl Rrxhurgc
DAquifir Nmmec nnJ Recovery
DANuifur TcA
DrapedmomwTcfhnulogy
D({WdWI'lllal (Closed ).pop)
OGcnlhtmtnl hlcntin /Conlin )future)
OGruundwmer Remediation
Onrricr
1:3Slunnwuter Drainage
CSunNinencecanunh
OTrnecf
001hcr citllnin under#211tcn1orks
a n•
19. NANDIGRAVEL PACKIfo IlcaMe
MOM: TU F4TFtx A,. KMPIACEMENTMKD1oD
n. h.
n. n.
30. 1.1.IN/:IqC a1lFeh if nese r
11fill
pROAI 110 DEBCIIInf1UH talon type, Reein ane ale.
DESCRnrION(to
0 ft. =j ft• Topsoil
1a1/18
4. Dale Willis) Completed. Well IDH
5a. Well Location:
Larry Gregory
pael1hy/Owner Nome l:"Oky II)d(I1,11"I ln,ulo)
192 Millwood Lane Angier 27501
{rl. o f
fr. n.
re (l.
h, ft,
ft ft
n ff.
phyxmal Addoms. Cikv, laid %ip
Harnett
County
t/k3�9•A�-04r on
IV'mavol Idoc6frnAlta No. (14N)
31 RVMAMKS
5b. Latitude and loughnlle In degrees/ndauteAcco is or dechnxl degrees:
Ghvoll not,[, alio IINIong to sul'6cien0
6. Is (ova) the well(N): OPermanent lir O'rempornl'y
7. In this n repair en lar existing well: Oyes at, MNo
If shot IAB IV,xdr',,1111 nn/ h..,rrn Irri/ etartrmllmal agdtol the ..arra r/elm
repair muter 112, rvmurrds.vrtOtt lir nn /ha bunk rr/dr Ac /uv...
S. NrmtUcrof wells mmit u,ml: One
purvanlllplr hllcrllnlrtl'torrneaht'c..pply mall+ONhVwill Am .x Ire caaxlnrellau unciae
mblall om,11+1'111. ,yI o
9. Tolnl well depth below Ionl surfoce: / (fr.)
For ruu/tgAu well., lhl all deaths ff rl/pervm p.rma,Ne. 3@200• aml2(lure)
10. Sntnt Wntel• level helov lop of caning: V?O (ro
if woler level le almvv em'lus, urn " I "
11. Rnrehole dlametcra 6 (1nJ
12. Well construction me(hod: Air Rotary
tic. miser, rntwy, cable, direct push, eta)
22. cntlo:
Nis , ora of Car I r We Conuvmtm role
ll, algnlnle INC final. I bmhy rerq(y 11..I Ale tull(.v) Ira,, (went comm"Cit Irl nevordnrrrt'
Welt Ido NCA(:' 020.0100 or ISA NLIC 020.0700 Well C(t)"I cdtt,7 "d..rdv Call rh... ..
ropy Cf Ihly revoul his,, Oeun prnvlrlrAar rhe n'cll mruar.
23. Site diagram lir oddillonal well details:
You may use Ilic back ofthis page to provide, additional well mile dcudIN or well
construction dcluils. You City also outsell additional pages if necessary.
SUBMITTAL INSTUCTIUNS
24m. nor All Wells: Submit this form within 30 days of completion lir well
construction to the fallowing:
DIV6101, of Water Resources, Information Professing Unit,
1617 Mull Servlet Center, Raleigh, NC: 27699-1617
246. For hllo'Dms Wells ONLY: In ntldWoo to ntndius 6w tier to the address to
24n Chole, also submit it copy of this Ibrm within 30 days of completion of well
consimotlon to the follpWinE:
DIVINIun of Water Resources, Underground Injection Control Progroln
FOR WATTA SOITLY WELLS ONLY: 1636 Mail Nervhce Cooler, Raleigh, NC 27699.1636
13n. Yield (gpu) J, Method of test:
Blow 24e. For Water SpnnlV & InlceUo Wens:
Also submit nnc copy of this tuna within 30 drays of completion of
131). DishlfeeUun type: HTH Amount: 1 Lb, well consallttion to tho county health department of the county whero
constructed.
Poin10W-I N.ah Cued!... DOInlnYat VEC11YINI11110111 and Nm11,'l1I IWOOC1COP^ DIVIOOLt at Water Rsciorelis Rovisod M,suxt 21) 13