HomeMy WebLinkAboutNew Well Completion Permit RHARL . fT DEPARTMENT OF PUBLIC HEALTh -.. RMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0643 -47 -1169 Parcel #: 08- 0643 - 0010 -01 Application #: 13- 5- 30756r Subdivision:
Applicant Name: Bill Swayney
Address: Deer Tail Lane F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25%
Permit Conditions:
Lot #: 2A
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 Age Date
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 Age Date
See Attachment for coV
on sketch
Application - 4:13- 5- 30756R Applicai. .name: Bill Swayney Subdivision: Lot #: 2A
Well Construction Sketch
Well Completion Sketch
lv
J
1.WELL CONTRACTOR:
A " H L
Well ontrra/actor(Individuan Name .4
"T ° Contractor Company Name
STREET ADDRESS., �. 490 �,A A?
/-;I c,
City QPt6wn State Zip Coale
) - 41y9 - 3� 3�
Area code- Phone number
2-WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT# (if applicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE: , �
DATE DRILLED
TIME COMPLETED 3!o-y
).WELL LOCATION: f/
CITY: .rte /`. V /= Mt`114 CID UNTY� /'T /#f ell
(Street Name, Numbers, COmmuraty, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC i LAND SETTING:
r
LATITUDE -� �/ —C� y May be in do grccs,
LONGITUDE minutes, seconds or
in a decimal format
Latitude f longitude source: 'PS
(location Of well must be shown on a USGS topo map and
aftached to this form if not using GpS)
WELL OWNER:
OWNER'S NAME
STREET ADDRESS f 0
c.ny or I own State
( 9/ L--&j 3 y/
Area code - Phone number
5.UVELL DETAILS:
a. TOTAL DEPTH: q�if'3
b_ DOES WELL REPLACE EXISTING WELL? No
c. WATER LEVEL 3,5-- FT.
(Use 4" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
"Tap of casing terminated at/or below land surface may require a
variance in accordance with 15A NCAC 2C _011$.
e. YIELD (gpm): ! METHOD OF TEST 41 f f"
Submit the original to the Division of Water Quality within 30 d
1617 Mail Service Center - Ralel9k NC 27699 -16.17 Phone No- (919)
E DISINFECTION: Type fi7jl Amount
g. WATER ZONES (depth): `
From— —2 ZZ To AP From To
From
TO From To
From
TO From To
6. CASING.
Thicknessf
Depth Diameter Weighl Matedai
From G'
To Ft-
From
TO FL
From
To Ft
7_ GROUT:
Depth Material Method
From O
TO AS- Ft - Qda'W/
From
To Ft
From
To Ft.
B. SCREEN:
Depth Diameter Slot Size Material
From
TO Ft. in. in
From
To Ft in. In
From -
TO FL in in
9. SANDIGRAVEL PACK:
Depth Size Material
From
To R.
From
To It
From
To FL
10. DRILLING LOG
From
To Formation Description
3 yo
A bra'
11. REMARKS:
100 HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wmi
15A NC,AC 2C. LL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD EN PROMMO TOTHEWELLOWNER
SIGINAAURE OF TIFIED WELL CONTRA DATE
i
PRINTED. NAME OF PERSON CONSTRUCTING THE WELL
ayS. Aft: lrfo mation Mgt, Form GW-1 b
r'33 -7015 ext 568. Rev. 7/05