HomeMy WebLinkAboutWell CompletionHARN''T DEPARTMENT OF PUBLIC HEALTH - RMIT
TOC, STRUCT A DRINKING WATER SUPPLN ,ELL
PIN #: 1527-29-9017.000 Parcel #: 021515 0403 Application #: 17-541216 Subdivision: NA Lot #: NA
Applicant Name: Gary Peacock
Address: 3069 US 301 N. Dunn, NC 28335
Type of Facility Served by Well: SWMH
Sewage System: 25% Reduction System
Permit Conditions: None
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 'ncluding location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State A Date SO—Ir— I%
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes F]N_o
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 0(144 Application #:1l-3-4016 Well Contractor: "cri U)
Applicant Name: cvy Peu"ate
Address: Ui O5 3c11 nen,, +L W544
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
Casine
1 i. uteri G 663-1
Total Depth: Replacement Well? ❑ Yes ❑ No
in. above surface. Yield: _ gpm at
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: n (above finished grade) Access Port: .rU Vent Stack: W
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer: NO
SampleTaken? Yes E;[ to Well Head properly sealed: 11-11
Remarks: W.,4.cr 4�mtwe ret.. sly a kLei po a e"'
Authorized StateAge t 'on sketchDate
See Attachment for comp
Application #:17-5-41216 Applicant' -,me: Gary Peacock Subdivision: NA Lot #- --A
Well Construction Sketch
PI'L0 pC�-c. 7-,K 1•-/ N T
I
� 30`
PB.IMAtLV
i a rzA _ _ ' �O- _ _ - j�j 3Brz 5am N
114 is
�r %i7l Sw.•nu
Well Completion Sketch
4
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1 "Q4L
P aSA
Yo'xyoi �
i
0
e� Z
i o u5 301
N A Nc ¢7
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I
I AfMOX.
35'
.ix-
_ 10,71
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5 W (vt N \
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WELL CONSTRUCTION RECORD (GW -1)
1. Well Contractor Information:
DGrnundwatrr Remediation
� ay -r -I WIII(%
/ J r-
Weli Contractor Name
[3statmwater Drainage
MU 3-ri-
OSubsidence Control
NC Well Connector Ceniflcation�umba
13Traeer
lly it\�fo�s hien
Drill�/lo�
Company Name
or muld-eseed wialal ORS -Dist t cab4
2. Well Construction Permit 41: i�'i711�12v1+ion#
X7 -5-y1 alb
kdri ell applicable well con901ednn permiu (?a UIC Caunfy, Smfl, t�orlmed, are.)
3. Wen Use (check well use):
Municipal/Public
(Heating(Coohng Supply)esidmtiel Water Supply (single)
munareial Residential Water Supply (ahved)
Well:
Recharge
DGrnundwatrr Remediation
Storage and Recovery
[3SalinityBatfier
Teat
[3statmwater Drainage
ental Technology
OSubsidence Control
nal (Closed Loop)
13Traeer
4. Data Wells) Completed: to'Q42-1-` Well D)#
Se.Y uy-i
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1'GW-I is needed. Indicate TOTAL NUMBER ofwe0s
drilled:
9. Total well depth below lend surface: (N
For multiple veto lint all depfhr TailiOrew (eeamplo- 3@20 ' and 2@100)
30. Stadc water level below top of casing:
brwater 16W/ is news cminrq, use
Il. Borehole diameter: �—
12. Well construction method: M k.d
(i.e. auger, rotary, cable direct puke, etc.)
'r`I CA Cock
faelllry/Own Name FacilityfDo (if applicable)
$e L4 tk,s 301 N' DOM A/ca833y
Physics) Addtm;City, and Zip
1�acne+i L,Sa'i a9 -9M?Edd
County Parcel Identification No. (PIN)
Sb. Latitude and longitude to degrees/miouteslsecoada or decimal degrees:
(if we0 Mid one Wining is sufficient)
3.S` a o .5711 Iv W
6. Ia(ere) the weD(e)ermanent or ❑Temporary,
7. L this a repair to an etirdng wen: OXes or No
IJr1ir is a repair, f/if oaf knows well cnmtrucnun l4farmaion d uplain The mature e(+he
repair under 021 rsmarts redinn er on the book
11
For Internal Us nly:
M WATER Z0111till
FROMTO
I DaOCRIMON
�R'
� tL
Co0.P5C SAn � YILve
ft.
fi.
15. OUTER CASD4
or muld-eseed wialal ORS -Dist t cab4
ITIOM TO
nLMETfA TmetOesae MATaRLL
.� h.
R.
a' in. sc H YO 1 PVC-
16..INNER CASIN
OR TE NIG eefher l elned-loo
efthis.farm.
11
For Internal Us nly:
M WATER Z0111till
FROMTO
I DaOCRIMON
�R'
� tL
Co0.P5C SAn � YILve
ft.
fi.
15. OUTER CASD4
or muld-eseed wialal ORS -Dist t cab4
ITIOM TO
nLMETfA TmetOesae MATaRLL
.� h.
R.
a' in. sc H YO 1 PVC-
16..INNER CASIN
OR TE NIG eefher l elned-loo
RROM TO
DIAMETER TID[RNFAB MATLIWL
fL
ft. I
In.
ft.
R.
In.
17. SCREEN
FROM IF
DIAMETER SLOT 8= I THICKNESS I MATERIAL
3�fL 3
a In,f ole Sc o-
10. GROOT
OM TO
MATERIAL EMPLLCRMENTMITHODA.AMOONT
D h. M
ft.
IRTUIt I OIAr Yq ✓1
it.
R.
— 50 u S
R.
If.
C l rn ilit CK o
19. SAND/GRAVU.
VACKlta Heable
FROM TO
at ERIAL EMFLACP.MENT ML'fNOD
oR
asB1T, oak- pT.V,r
ft
n.
20.A INGLO
Ath4
additional been Cneean
FROM TO
DESCRIPTION 4010, IUAxeo tonlmh m dM sot
_
q. h
fL
n.
7QA C a
wars n tt Afic
R.
ft
R.
ft.
R.
R.
u.3 E A=S .
22. Certification:
Dow
Sy sige nS chh, form, herby crrdfy that ine well(:) war (wiry construcmd in accordance
with /S.f NGC 02 7. 00 or 1Sd NGC 02C.0200 Well Consrraenon Standards and Maid
4wpy of fhb record h 0�n provided m the wall owner.
23. Safi diagram o4 addIdonel well details:
You may use the bank of this page to provide additional well aim details m well
construction details. You may also anach additional pages if necessary.
24a.
to
24b. For fill
above, also out
construction to
Division of Wa
FOR WATER SUPPLY WELLS ONLY: 1634
134. Yield (gpa0 ��_ Method of test: In G 24c. Fer grater S
(t `1 the address(es) ab
13b. Disinfeetlon types else Amount: ` �--4'� completion of wel
where constructed.
Submit this form within 30 days of completion of well
star Resources, Information Processing Unit,
Service Center, Raleigh, NC 27699-1617
Is: In addition in sending the form to the address in 24a
copy of this form within 30 days of completion of well
Resources, Underground Injection Control Program,
ail Service Center, Raleigh, NC 27699.1636
ply A Inlection Wats: In addition m Sending the form to
, also submit one copy of this form within 30 days of
)mtmction to else county health department of the county
Pam GW -I North Chmlins Department of 0evironmental Qoality - Olvision o(Wate+ Refourcec Revised 2-22-2016