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HomeMy WebLinkAboutWell CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PFDMIT TO CC TRUCT A DRINKING WATER SUPPLY LL PIN #:0517-34-4110.000 Parcel #:01236.0028.20 Applicant Name: Barbara Sanders Address: 192 Mount Vista Dr. Lillington NC 27546 Type of Facility Served by Well: SFD Sewage System: Conventional Permit Conditions: Application #: Subdivision: Little River Plantation Lot #:103 General Permit Conditions: • Drinking water supply well construction must meet 15A NCAC 02C.100 rules • The permit[ drinking water supply well shall be located in accordance with the SITE PLAN • ANY ALTERA f the site of the site (including location of structures and appurtenance) or modification in use of the well, may subject this P o r a Authorized State Agent RL Date �±-la)1 s Grouting Inspection Witnessed N Date ❑ Grouting self -certified by driller GW -1 provided? E]Yes ❑ N_o See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: 41ay1 XApplication#: Well Contractor. 5o>iN 11 $e�l�TE Applicant Name: bAo bq¢P S a.�.Oms Address: 101--k n•un'c visTtt O2 - Directions to Site: Gw Use of Well: —Date Drilled: _ Total Depth: _ Replacement Well? [--]Yes ❑ No Static Water Level Top of Casing is _ in. above surface. Yield: _ gpm at Disinfection: Type Amount Water Zone (deoth) Casine From _ To From To From _ To _ Diameter: _ _ Material: Thickness: _ From _ To _ From To Diameter: Material: _ Thickness: _ From To _ Diameter: Material: Thickness: Inspector: On Hold Date: Release Date: Remarks Grout From 0 To _ Material: Method: _ From To Material: Method From To Material: Method: Well Head Information / Casing Height: 11_ (above finished grade) Access Port: Vent Vent Stack: t/ Well ID Tag: V Pump ID Tag: ✓ Sampling Tap—.:—;7, ap: ; Backflow Preventer: _ Sample Tak Yes x No Well Head properly sealed: Remarks: Authorized State See Attachment for completion sketch Date 8 Application #: Applicant Name: Barbara Savers Subdivision: Little River Plantation t-ot #: 103 Well Construction Sketch W 102 o SJ �/J P26A _ SC JFO rys• I .I w6zL I Well Completion Sketch John H. Boyette Jr. Well ComactaNme 2505 NC Well Comsaar Cwti6mtlw Nembc Boyette Well and Septic Inc. CompeW Name 1 Well Cowetacthm Permit*: lLr alfoPPltm64 W.ao,een,a,I,aPr, p,a: '...0 -ow SmN, Varsawt.a4) + 3. Wen Use (check well oo). )Ag ioultutal ]uimebennel °p Supply) SDPP1y(elQO) n Imooft-vCommmeW ORoldentiol Wow Supply }rt�tion 11,I yBenla T 13SmrmWUI Dramop gwta d Tcdmolw 06tbaldmme Cooky :: e, (Ckw LOOP) r lTro v d. Date ww,,)Compfoted, i/ f1V WCBW# t UUMWV-W . N. (PIN) 30. Ladmde and lwgW ds m depeeyadpueuheCo@& or dedtosl degrees: (if wall one �s 32 �16)N V [ y`y�� � O 1 W 6 food) an wer(q�Peramsat or QTempaeaty 7. U Ihls a twpair m spakalwg we1L ©ys, or ®No 4rM4/ranpeir,J01fhiewWrlleuamtatlonWZ11miono.d VJerhenamnejMe npntreadrr o71 reaurkr soMon w oe tho MckqfMk f� L For GeopwM or tlnwdd_P Ga�ereW WWW hov* the omtetruotlon; Drily 1 OR' -1 ie Doodad. kidlab TOTAL NUMBER of ®o drilled: wells f. TOW wan tlopeb below food awfoce: _ Por a.tl®le WUrlldoll dew p'dlParrefiamrPle!®7a0 ord)((ylen') It Smtlt water level below mp of take, 4rWaln lad/r avow"... '4 _.. '7 (h) 11• Borehole dlataeten r 6 12- Well eseut urtim method:(' (tte. ooYm. mtny, eahq ditwa pork Z) 1e= R IL A R IL 10 001 a C 'n1Y oPall gY rI dersbP arryy Mol Mt W/W wat ItWo) aamoaad M aeroMorin -10IJA ACO1C.0140 a1lANCAC 01C,07(p WH C.,,..,. S..bdr mrd/Amo ropy O"W, retwd lm 6—P &Wo, 6b well oWeer. 23 8111a, dlpnm or a iftmel Well detane: You mq utm the bade of this pogo to Provide a"dmml well sloo dermis or well mootrDation daoiln. You may Gini sa.A additloml pages if WM,,y. SLIBMITTALMMMUCrim 20a Far ADW l-' Submit dtis form within 30 dare of mmploCoo of well construction to the &rowing: DlvWon of Water lit ..... 61Dfosmotloa Praea.iDg Uedt. 161711Lr Savlea Ceomr, Relelgh, NC 27689-1617 Tdh For I dUg WdF fo addition m M4 the Cam m the ad&eea in las above' aim mth®" Dtw Dopy of thio form withm 30 day. of oamplwoo of well conanmlion to tho &roping; 80R WATER SUPPLY wEUS ONLY: ')'V'd a o(Waar Reao,g Tea, Uedcripl and Inleedon Contra] Prog<amr 1616 Mar Seevin Center, Ralsl6h, NC 27699.1616 1h Yield (nme) Method dcert�� 2de. Har Waer-- lab. D4lohct"m Hth the addtm(a) alcove, afoo submit one fo .ddmon m within g dm Sacco to T)T°' Amount 16 02, ,mpl um oP aer conetrumlDn m rm °oP3' of thin form widtiD 30 days of whore oananm eti. Domuy health dopmmt<rit aft oouoty Form OW -t Noah Carolina DOIan=°a' of Fa°ir�d 2miky • nh+.b. atwam a.oaoer Rawised 1-32-J016