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New Well CompletionHAk_ .ITT DEPARTMENT OF PUBLIC HEALTH_ _ ERMIT TO CONSTRUCT A DRINKING WATER SUPPLY WELL PIN #: 1601 -16- 6891.060 Parcel #: 0716010037 Applicant Name: Stancil Builders, Inc Address: 466 Stancil Rd Angier N.C. 27501 Type of Facility Served by Well: SFD Sewage System: 25% Reduction Permit Conditions: Application #: 13 -5 -31695 Subdivision: 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 Age - �--� + f}„� u Date_ Grouting Inspection Witnessed Date _ ❑ Grouting self - certified by driller GW -1 provided? O'Yes ❑ No See attachment for construction sketch "7- Z -5 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 Aget Date %� t See Attachment for comple itch Application #:13 -5 -31695 Applic Name: Stancil Builders Subdivision: Lot #: 1 Well Completion Sketch �. .Is- 5 1 1 a rr"O Aug, 14, 2013 4:25PM Vo. 3701 \.P, 1 RAMIRMDEPARTMM OlrZUMCHZALMPPJMW, TO CONSMUCrA.DjUrava, WAM stm. Y"W Poi A. Subftmow La.#; ow=alramitceajw; DrInkft wwr "nC=Wwft6-M-WI5A?ICACO2Cj00nAW MYO' Cadon iltuseof *web may Date 13 LEW-lpMviftd? LJYCS ) 1Vfu" S-sftCbMMfbr WELL CUMMCATE OF-COMLEnor4. Data AppMa*mter Apok.g=.:a�C; 1 p Adkm 4. r utecemwsian c) T. D�doa: Type f yz�lwsw ye ETN' a ='un, MO4=w � at Bra, RM .VM"95 F la TO From — To F►omft To Q CA-ft'Q^4 From _ To %ftem Diesaetat TQ FEM — Thleb, m �— To Fmm _ To Know. — Afthyd- Ahtcrid. Tt From To Oa Hold bm, R&m oat,. Remaim Zdadhazlon C" Hgft — (ohm &-Aw Z.,YC) Acm.Parl- wea ID rag: PMPM Tfil: T4�— VCCLL Sad= — uwt&TW6 .7 No Well Ffmd prqpa(y &CAW, Rqtwb• . Akrtkwaed Soft Ag=l Date Aug, 14, 2013 .,, 4:17PM Eryd o �h�M yA� y � No, 3699 P, 1 EsIDENTI�L w �i. �oNS Cx�oN rcORD Nord% CuolinaAapaftl:nt of Spvironunvnt and Natural &sources- Division of Water Quality WELL CONTP447TII CERTIFICATION # .?44- t, A 1. WELL CONTRACTOR- 9- TER ZONES ( ►hj; Top Bottom Well Contractor (Indlvldueq Name • a��_ Tope Bottom^ t T°p - — Bottom. Top Bottom�� Wall Conlrgolor Company Name — Top — Bottom Topes^ Bottom SlreeE'Addresg : WErlI 7. CASING;, Depth biametar Thickness/ Weight Material Top ,�;! Bottom % I. own _ 7591 City or Town To -�'� �^'F ^ p Bollom�^ Stale ZIP Coda t 91 g »Q' w� Top•— „, Bottom Fl. —'-” area coda Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# " .�' �j` �q� Top GROUT. �� ottom � Ft Material Method Bottom Top OTHER ASSOCIATED pERMiT #(Irappllvebie) Bo(tom F A psi � Top,,,, Bo(tom Fl SITE WELL Ib #(Ir applicable) - -^--�- 3. WELL USE (Check A pllcable Box); . Reeldenllal Water Supply f" : 8. SCREEN: Depth Diameter Blot Size Materiel Top Bottom DATE DRILLED l 3 I Fl, In, In. Top Bottom In , TIME COMPLETED AM C PM In, T (, In. In. 4, WELL LOCATION: // CITY; �^7v��i" COUNTY// 10.9ANDIGRgVf~LPACK: Depth Size M$terlal Top _ Bottom Fl. (Street Neme, Numbers, Cotnmunlly, BUbdIV161on, Lot No., Panel, Zlp Code) Top_, 9 °llI_, F1' �- —�-- TOPOGRAPHIC ! LAND SE (check'e pptvprlaie box) TOP—Bottom FL_— uslopa ovalley at ❑Ridge 00th ®r : LATITUDE �gpi LIZ, bMS 11. DRILLING LOG Top B °I,?Om OR LONGITUDE � pZi.py�i "DM$OR�..: �Formation Descdpllon / -LST,° Lalillld'ellongIIUde source: p3pS i ropographlc rr(ep (locatlon of w" must be shown on 9 USGS III map 6ndeftached to this (onn Knot Using GpS) _ G. WELL OWNER / Owner Name > JIL Slra 1 Address fly or own^ Slate zlpCvde Area code Phone number 6. WELL DETAILS: \ a. TOTAL DEPTH: ©S 12, REMARKS, La b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO c. WATER LEVEL BeIoW Top or Casing: Q % 0 --�Fr, (Use �4" If Above lop of Casing) I DO HEREBY CW IT 1 THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC ZC, WELL CONSTRUCTION ra. TOP OF CASING IS ' FT, STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. Above Lend Surface' 'Top or casing term [naiad 11V0 below land eurrace may require a variance In accordance with 16A NCAC 26 �/j ,0198. e. YIELD (gpm); -� METH TEST 0 A --� a SIGNATURE .1 DATE f. DISINFECTION: T�rpp Amount �; %. PRIN ED NAME OF PERSON CONSTR TING THE WELL SubrttlIkf►i r� MR.!, 161 'Ma(($��i Vssi�� tec,,.i�ua 96714i a • tnftsnitatloK��ogam ®ing, Form GW1 a Rev. 2109