Well CompletionHARNF—T DEPARTMENT OF PUBLIC HEALTH PFRMIT
TO Cl ,TRUCT A DRINKING WATER SUPPLY :LL
PIN #: 0692-78-0141.000 Parcel #: 070692 0036 033 Application #: 17-5-42291 Subdivision: Joseph Gerrell
Applicant Name: Richard & Rebecca Lamy
Address: 3717 Melrose Drive Raleigh, NC 27604
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - 229 Ablitzd Lane Angier, NC 27501
Lot #: 1
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 went Date 1-2 e-17
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: a /0;1/($ Application #: I1 -5-14M Well Contractor: t"Tip S 'ty
Applicant Name: Y iG c(cPd d 4lzbYccN
(r
Address: 5cv-e._
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)
Casine
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: t4 o hished grade) cess Port ✓ Stack: ✓_
Well ID Tag: Pump ID Tag: _/ Sampling Tap: ackflow Preventer.
Sample Taken? es ❑ No Well Head properly sealed: .
Remarks: _
Authorized State Agent �Date 0-41 or2l oior6
See Attachment for completion sketch
Application #:17-5-42291 Applicant T' ne: Richard & Rebecca Lamy Subdivision: Jo—ph Gerrell
Well Construction Sketch
Well Completion Sketch
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Lot #: 1
Jun. 6, 2018 5:21PM
WELL CONSTRUCTION ORD
Tide foreseen be uecd for aimBle or mduplc wells
1. Well Contractor IDfurmadon:
Felton Jacobs
well Cannemor Nemc
2765A
NC Well Contractor CnnotationNumkr
N.W. Poole Well & Pump Co.
Company Name
7.. Well Costatrncilse Permit lit
lar oil vpplkabb 11x0 pannus p.e, Cow19, SPot9, Yarlanee, MfecNan, Na.)
3. Well Use (check well use):
OAgricuitural OMunlcip9VPublic
OGeolhermel (Heating/Cooling Supply) m t(midential Wolf Supply (single)
❑IndmilieVCommeroial OResidenliai Water Supply (shared)
OAquifer Recharge
OAquirer Storage and Recovery
OAquilter Test
0aperimentel Technology
OGeothennal(Closed Loop)
4. pate W ells)
County
OGroundwoler Remediation
OSalinity Barrer
OStormwaur Drainage
Milbsidence Control
OTrecer
�Cc4 Lorry
FaeilitylDd (Nepplluble) .
0V _7$-b141.000
Parcel Idcmi(udoe No. (PIN)
No. 8659 P. i
Nr Imemal Use ONLY:
nom To�•es t •rtion""_.:e:;.::eti.;>.:
h. R
n. rL
-. .
FR 1 T D ETER THICKNPba MATERIAE
h.I V1 h n, 1,4111 ,
'tet ''A` QRG" 'b fiIBD1G; 'sella` ditll'flosed4 6 d� '
FROM I TO I 016MLTZP TMICKNESS I MATMAL
it. I (L I In.
n
it. m,
FROM I TO nrEa SLMSIZE I y IC N ATEmAL
ft f1. In.
'Pam ITo, t HAT
•->u:•x S.. . N
0 *fL20fLfL
f,
PI I
, 9> IGMYQIlYX616 In " d tl L ..:.'e+': a;.:wc:'"a'4'*n:, •�.. ,,
MATERIAL FL CEMENTMETM00
fl, rL
I, R
FROM PESCRIPTION calor hard..wIVr..ka, ode V Nrj
n. n _rnl CA
—CL
n. d ra G
O (L L (L �n
n. n.
n. fL
n. IL
:: aeeDURfraac',, ; �..x rr.;s;.:„-,;.:•- ..
Used hardened steel drive en oe
5b. LBNtude and Longitude In degreellalnul alaecoads or decimal degrees: 22. Cer118uN0p:
(ifweil field am hdlong u eulpeum) 6 -
Is3� .N •-�$.�-� s�a� W �
Sigmhue fGerlided Wag Con rot ere
6. to (ere) flit wad(.): SFermanent or OTemporary E
7- Is this a repair to an existing wall: [IV” or I�
Iftho b o repolgn0 out Arinm well faMDWnan INformonon and explain the MIUM o/de
r<pa;r imdar 621 "maria rentor, ar aN the back Vr hgfarm.
1
0. Number of wells copdncted:
roemainpl. byamon or non-walern pply WIT ONLY rW/h the Some conrnddlon, "I, ran
dibn,ll ores firm.
9 -Tool well depth below loud suffice: I q 9 (R)
Far11UNFle well, NNalldeplln tfdfrnt(example-3 2�0'10'sats®100)
10.5MIC Witter level below top of easings. O(� ((L)
�
ffr«ares GvellS obovaSa:m(, use "•"
11• Borehole diameter: 6 (ID.)
O$Iy
12. Well construction mMhd:
o
O.e. auger, relay; ubh, direct push nn)
Y S/gronS thin form, 1 herby real& Ihei the welt(,) war (were/ commurtM In acr.'o...
w10, 15A NCAC 02C.0100 or 15A MAC 02C L0200 Well Cwnln¢llon Slander& and Thal a
mpynfdl, record har been provided w At iWitowner.
23. Site diagram or additional well data Us:
You may use the back of this page to provide additional well site derails or well
tonslmctiondeuils. You may also attach additional pages ifneccssary.
SURNUTrAL 1N3TUCTiONs
24a. For Ali Walk: Submit this forth within 30 days of completion of well
construction to the following
Division of Wales Resources, taformadon processing Unit,
1617 Mag Service Center, Raleigh, INC 27699-1637
246. Forinlnellbn wen. ONLY: in addition to sending the form I0 cite address in
24140ve, 6190 submil A copy of this form within 30 days of completion of well
eonsimetion 10 the following:
Dlvlalon of Water Resources, Uadergrouod 141tedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center, Raleigh, NC 27699-1436
130. Yield m"50 Blow 24L For Water SupBiv& tataction Welts:
(gotten) Method of lora
H Ib Also submit one copy of this form within 30 days of completion of
13b. DRiafee0on type: AmouDL• well comlruclion to the county health department of the county where
constructed.
Fomr GW.) North Carolina Department oflEovhaMoent and Nmm,(;w,,weee- Division ofWaler ResouNw RevieedqupuN2013
Jun. 5, 2018 5APM
WELL CON9TRUCTtON FC tD
!less term unbeusedforot! mmuhlphwenn
L Well Contractor 100terROOn;
Pelton Jacobs
tach Comrade, Name
P -765A
NC Well Conusdm CedRndon Nnrnber
N.W. Poole Well & Pump Co.
Company Nome
7.. Well Cooslruclloo Permit n:
lin all appllro61r ,sell penolls O.O. Canny, SIOM, parim,ce, 1*11 n, ur)
3. Wall Use (0hcck well use):
D Agricultural ammicipavNblic
OGeodlermal(Realing/Cooling Supply) 016aidealial Water Supply (single)
Dlnduslrial/Commerelel OResidenlial Water Supply (shared)
OAquifer Recharge
OOmundwater Remediation
DAggifer Storage and Rocavery
OSalinity Barrer
DAquifer Test
OSrormwatet Drainage
O6xperimental Technology
OSubsidence Control
OGeothennel (Closed Loop)
OTreeer
4. Date Well($) Completetk, --T
c1Cq �mlf
Rciliy ID Wgppllnble)
C12;
002 /O -m l+L ODD
Pared ldcn66carinnNo.(PIN)
Fm Internet Vac ONLY:
36. Latitude and Longitude In degree/miouto/seconds or decimal degrees:
(ifwell geld, one hVleng to rutgeieni) y 22, Certification:
35.k��53a�_N 7S,Co13ga`1 W ;. &
6. Is (are) the well(s): ePermanent or OTamporary
7. Is this a repair to an existing well: DYe or Ofso
Ural, U o npab, flit ourknown w,/I eOruervdlon lhfOrmaflan oad exploln the Ohre ofil,
rupolr wider 121 remarks seenon or on she back 9frhbfmm,
C. Number of wells construcled• 1
!or mvlslp/s InJt<aori ornon•wmrrn ly wens ONLPsvIIN INe earns ronmae0oa, YOU CO.
subpar ans/orm. ,
9. Total well depth below land aurfare: ! �I LI (R)
Gornwldprr dells 14l bll depiAi I/different (uomp/a- 3�]00'ard7@l00)
10. Static water level below top of casing: a O (R,)
4r,raler Ievrl is abowsming. use '4"
11. Borehole diameter: 6— �lp�gry—(lad
12. Well construction melbodl
0 e, BUBO; Oory, Coble, direct pub, em,)
No, 8654 P. 1
By stgning Ws form, f hmeby een fy dnl dre wells) ,von 6"m) corulrucsed I. o..... f ar
whh ISA NCAC 070,0100 ar IJANCAC 02C.0200 Well Conrvnrcnon SrorMords mud Ilml a
copy a/Ihls recardIm been provided ro INe well owner.
23. Site diagram or addltlonal well details:
You may use the back of )his page to provide additional well site details or well
conawnion details. You may also attach additional pages 1(hecessary,
3UPWnAL INSTUCT1ONS
24a• ERE Ali Well : Submit this form within 30 days of cmnpletion of well
COW[mclion to the following:
Division of Water Resources, 1p/olsneuon Processing Unit,
1617 hfaBStmice Ceptor, Raleigh, INC 27699-1617
24b, Fpr hsleclled Well ONLY: In addition 10 sending the form to the address in
248 above, also Snbmh a Copy of this forth within 30 days of completion of well
construction to she following:
POR WATRR SUPPLY&LIS 1. Division of Water Resources, Underground Injection Control Program,
/W� ONLY: 1636 Num Service Coater, Raleigh, NC 27699-)626
Meshed of let:
136. Yield (,:Pm) - BIOW 29C. For Water goopl ••1 & H..w Ih•
136. Dlslnfecdop type: H Amount: Ib' AI30 Submit one copy of this form within 30 days oCGompletion of
constructed. well construction to the county health dopanment of (he county whew
Fo rn GW -1 North Ceratins Doparanent vfEovnonloent end Nebnl Reotvus—DiWeion of Weler Reaourcm
Revised Augu311013