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HomeMy WebLinkAboutNew Well CompletionHARN 'DEPARTMENT OF PUBLIC HEALTH .MIT TO COivSTRUCT A DRINKING WATER SUPPLY WELL PIN #: 1507 -38- 2654.000 Parcel #: 021537 - 0110 -23 Application #: 14 -5 -33904 Subdivision: Walts Crossing Applicant Name: James A Peterkin Address: 70 Delaney CT Type of Facility Served by Well: SFD Sewage System: 25% Reduction Permit Conditions: 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 Ag t C. Date "LN —1 bl Grouting Inspection Witnessed Date ❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: Application #: Well Contractor: Applicant Name: 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) From To From To From To Inspector: Remarks: Casing From To Diameter: Material: From To Diameter: Material: From To Diameter: Material: On Hold Date: Release Date: Grout From 0 To Thickness: Material: Method: From To Thickness: Material: Method: From To Thickness: Material: Method: Well Head Information Casing Height: (above finished grade) Access Port: Vent Stack: Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer: Sample Taken? ❑ Yes ❑ No Well Head properly sealed: Remarks: Authorized State Agent ��` Date 8-70 -- /F See Attachment for completion sketch Application 4:14 -5 -33904 Well Construction Sketch Applicants ie: James A Peterkin Subdivision: Walts Crc Lot #: 1 Well Completion Sketch Aug 20 14 01:58p CANNADY BROS 9105642077 p.2 North Carolina Depm1r i jco; nvkonmeatandNat Resources- plyisijn of Water Quality WELLCONTi2ACT6} V.RTTFTC'ATr()N 7t i, II t 1. WELL CONT Ronald. G. Well Contractor Cannady Br well Contractor 1366 Bass Lake Street Address Roseboro City orTown 9� 10 564-52071564-4733' OR. �rrrlad�r _ To) : To = •Ta _- T. To 8382 - To Vp Code Ta WATERZONES �sa�am Boom Bottom SING: Dep1h a Baao� ,� ry Botto,'n Sotto ( ). `1 Tap eattam Fop Bottom Top Bottaln Thfcknesst Diameter Weight Material Ft. c y0 p'}cj FL �3 ` s,4 4_� PUS FL lndividuaD Name `fibers Well Drilling, Inc. Name Road . NC 3 State Area code ' Phone 2_ WELL INFO WELL CONSTRi1 OTHER ASSOCIATED SITE WELL ID #(fi 3. WELL USE (Ch DATE` LL H.Q TIME•COMPL 4. WELL LOCATI r►umber TION: !T1aN PERMITS ! �' PERMIT #0iappkable pplfcable) Applicable Box): Residential Wate % ),'3 0 AM P D = a.! ; TO; To Tor 9- ply ['� = Ta Tor To ; 10. Dept Bono Bottoi Botto CR'E)EN: Depth a 7 Bottom Bottom ANWGRAVEL a�� "� Method Ft V � Ft Ft Diameter Slot Size � Material Ft a �� in_" �j Z in_ 1" o� Ft in_ in_ Ft in. In. Im o� Su PAC II. ctrr: (Street Name, Nu COUNTY r " To : L? f } �% �.2- ?ro p Code) To Depth a V Bottom Bottom Baft Im Size Material Ft LK 11 t? Ft —� Ft r •� 3 : bets, Cvnunum'Ly, Subd'nrision. Loi No., Pa r, TOPOGRAPHIC DSlope Qvalle LATITUDE f LAND SETTING: (dierk appmpftle fat DRidge ©Other -210 - � "DIUIS W010CW= ) 11. Top DD DRILLING LOG� Bottom Formation Description l 1,7 1 LONG711E 7 Latitude dad 9 (tocaL'on of well this form ifnat a , °:3 5, .13 0 pt;�s 7 'source: C` pTo potapo c map - usFlse shown on a lists topo map a 'n4 GPSJ DD ched to i U ! 1119 / Z. S. WEL OWNER / 1 1 O Name t .L / Street Address / 1 City orTovm �'d Slate 61 2ipCode / I REMARKS: Area code Phone 6. WELL DETAILS: a. TOTAL DEP aumber ryry : d = 12 1 T THIS WELL WAS CONSTRUCTED IN NCAG 2C, WELL CONSTRUCTION COPY OF THIS RECORD HAS BEEN OWNER f. WELL_ CONTRACTOR DATE 11 6, l N CONSTRUCTWG THE WELL b. DOES WELL c. i�trATER Lc i• �' (Use d. TOP OF CA5 -Top ofcas a vanence e. YIELD (gpm} f. DISINFECTI REPLACE EXISTING WELL? YES [I L Below Top of Casing: �. " +° if Above Top of Casing) G iS FT_ Above Lanc gterminatedat forbelowIandsurface in aoconfance with 1SA NCAC 2C .D11 Co lamiOD OF TEST - : Type 14 7 (4 Amount O ID FT_ AC ST = PR rface requQe SIG HEREBY CERTIFY RDANGE WITH DARDS, ANDITTHAT VIDED TO THE Gs[C -I IC 5 WE Stj a . I TUBE OF CERTiFi /Z ( NAME'OF PER C : PRI Sub mst;livitiliia.3 acts :ear :a ca:.: ' d'a's.of com tefion :to :'Di�ii iq Y. P ... -_.. r►a'..�.: _:o�ia :.:6`' =L1F '97CAO''dCd•c k ' ofWaier.tlual _:- :•e- 140401 2n7: 'kiforinatiors Pr' essing;' Form GW -1a