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HomeMy WebLinkAboutWell CompletionHARNET' EPARTMENT OF PUBLIC HEALTH PEI 'T TO CONSTRUCT A DRINKING WATER SUPPLY WELL PIN 1516-23-0863.000 Parcel 02-1517-0785 Application 07-5-17908 Subdivision: Lot P cant Name: Lee & Jeanette Herrine iress: 2501 Parlimont Place Dunn N.C. 28334 Type of Facility Served by Well: SFD Sewage System: CON Permit Conditions: 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 s Authorized State Agent-a.~ Date_ Grouting Inspection Witnessed Date _ ❑ Grouting self-certified by driller GW-1 provided? ❑ Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION I , Jrj Date: Application 1-7'i&9) Well Contractor: t--14'' c , kr icant Name: Address: C:~d,: -Y►+'►~ u r JA4/hN- Directions to Site: Use of Well: Static Water Level: Disinfection: Type Water Zone (depth) From To From To From To Inspector: Remarks Date Drilled: Top of Casing is Amount Casing From To Diameter: From To Diameter: From To Diameter: On Hold Date: -7._iZ V Total Depth: in. above surface. Replacement Well? ❑ Yes E] Yield: gpm at ft. Material: Thickness: Material: Thickness: Material: Thickness: Release Date: No Grout From 0 To Material: Method: From To Material: Method: From To Material: Method: Well Head Information' Casing Height: (above finished grade) / Access Port: Vent Stack: Well ID Tag: Pump ID Tag: / Sampling Tape Backflow Preventer:, Sample Taken? [Yes ❑ No Well Head properly sealed: z arks: Authorized State Age { Date See Attachment for completion sketch :5-17908 Applicant Na Lee & Jeanette Herring Subdivision: Lot enstruction Sketch l t. (1 1~+e.il JTN~ t ~4•!- f9 Af 77 ~ 100 ~ Completion Sketch S(L I-11)0 P.1 WELL CON$ u(: ®N RECORD North Carolina - Department of Environment and Natural Resources - Division of Water Qua]ity. - Groundwater Section WELL CONTRACTOR MUDtmuAL) NAME (PriatLLaurv Williford WELLCONTRACTOR cowANYNAME jetty Wi hH-Md's Well Drilling CUTIkICATION #-U63 STATE WELL CONS71tUCTI0N PERb11T1 PHONE M 1910 5672579 _ A~oaATED W Q PZ M1TM (ifattplicable) Are. L WELL USE (Check Applicable B <m): Residential'd MunicipaWublic ❑ industrial ❑ Agriculpual O Monitoring ❑ Recovery❑ Heat Pumup Water Injection ❑ Other ❑ If Oth List Use 2. WELL LOCATIO Nearest Town: ~ L~ n A Coum cr/i - - TopO8WhiQ1.=d setting 1A10 , c,tte n ~av:~-r mdse ❑Slope ❑vanry PFlat (Sheaf Nuaq,Nr umb ers. Community, Sabdivisoon, Log No. rjp Code) (CIMA apFq date boo Latitude/longitlide of well location 3. OWNER: ee J' e re, "A d- er%a a (deB~skaim~sreoonds) Address . 5 a I Gt/1►'1 (StreetorRowNo.) LmitudtJJlorugitnde source: (shed ox)opograp} map mac- a~33 ~it or Town Soft Tap Code From TO 12R1LLINti LOG Formation D 'ption Am code- Phmemmtber 4. DATE DRUM o2'~ ro -I a'- re I t1 e- a S. TOTAL DEPTH:_ 3 ` (aYa_k 1 A, C c~7t 6. DOES WELL REPLACE EXISTING WELL? YESI'NO ❑ . G 7- STATIC WATER LEVEL Below Top of Casing: ~~r5~ S e, vEc! 8. TOP OF CASING IS (Use *+"irAbaw Top of cubg)* ET. Above Land Surface 'Top of e"Ing terminated aNa r below bad sorfasa requk s a •arlaaea In srwrdaaea with 16A NCAC 2C.011L 9. YIELD (Bpm): _ 40 Ma EHl ODOFTEST 10. WATER ZONES (depth): -3 S 11. DLSINFFCfiON: T ( LOCATION SKt=T YPe Amount _ 2 Show direction and distance is miles from at least 12. CASING: Wall Tbidmtss two State Roads or County Roads. Include the mad D ter SSG © VG numbers and common road names. From To Ft. i 1 From- To Ft: From • To FL 13. GROtrb Depth atrial F To_ Ft L M c'i! r~` Fro_ To bd n Ft n( vo 14. FCroREm,f, TDeprbFt_ ' U~ Mft" ~t I in. YG 1 From To Ft`_ _in. ice, Ldz it 15. SAND/GRAVEL PACK Depth From To 3~Ft.. ~ cc a Gf~ t~ From To Ft_ t 16. REMARKS. I DO HEREBY CERTIFY THAT THL9 WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL 170NSTltUC 170N STAVDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED lip THEMELL OWNER 01- • A J If 2 `rl'13A'RtvOA nun vc ccaaavPt aXi1VS1KUl.1INGTBE WELL DATE Submit the original to the Divh1on of Water Quality, Groundwater Section, 1636 Mtdl Service Center - Raidgh, NC 27MI636 Phalle No. (919) ==I, within 30 days. OW -1 REV. 07/2001