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Well Completionu HARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT TO CONSTRUCT A DRINKING WATER SUPPLY WELL PIN #: Parcel #: 070588 0063 05 Application #: 14 -5 -33337 Subdivision: Lot #: 1 cant Name: Sally Doyle Address: 3180 Crawford RD Erwin N.C. 28339 Type of Facility Served by Well: SFD Sewage System: Conventional Permit Conditions: 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 ent /3� Date % —jy% Grouting Inspection i ness ,a... Date ❑ Grouting self - certified by drill--,' GW -1 provided? Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: Application #: Well Contractor: A ,,,ticant 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) Casing Grout From To From To From 0 To From To Diameter: Material: Thickness: Material: Method: From To From To From To Diameter: Material: Thickness: Material: Method: From To From To Diameter: Material: Thickness: Material: Method: Inspector: On Hold Date: Release Date: Remarks: Well Head Information Casing Height: (a ove finished grade) Access Port: Vent Stack: Well ID Tag: Z Pump ID Tag: Sampling Tap: Backflow Preventer: d Sample Taken`? es ❑ No Well Head properly sealed: arks: Authorized State Age Date See Attachment for completion sketch Appiication #:14 -5 -33337 Applicant Name: Sally Doyle Subdivision: Lot #: _ Well Construction Sketch J" N . Completion Sketch Jun 11 1406:45a WELL CONSTRUCTION RECORD This form can be used for single or multiple wells 1. Well Contractor information: Roger W. Jackson Well Contractor Name 2179, -,j NC Well Contractor Certification Number Jackson Well Company Comp nyName , 2. Well Construction Permit t1:O• o 00'6 10 S List all applicable well permits (L a Couruv State, Yariance, 1*ecdon, etc.) 3. Well Use (check well use): Water Suppy ❑Agricultural ❑Geothermal (HeatinglCooling Supply) ❑ Industrial /Commercial Non -Water Supply Well: ❑Aquifer Recharge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ❑Geathermal(Closed Loop) ❑Geothermal fHcatindCoolintt i OMunicipaljPublic ential Water Supply (single) OResidential Water Supply (shared) OGtvundwater Remediation OSalinity Barrier ❑Stotmwater Drainage ❑Subsidence Control ©Tracer I3Otber {explain under 021 F 4. Date Wells) Completed. .... Welt um. Sa. Well Location: Facifity/OwAr Name I Facility Mb (if applicable) Physical Address, City, d Zip County Parccl tdcntificationNo. (PIN) 5b. Latitude and Longitude in degreesiminuteNse conds or decimal degrees: (ifwell field, onclotilongissufficient) 70e -73-3 w 6. Is (are) the well(s): BPermanent or OTemporary 7. Is this a repair to an existing well: ❑Yes or E71�o If'thir it a repair, fall out knouv well consbucalon information and explain the Harare ofthe repair under #21 remarks, section or on the Zack of this form. B. Number of wells construe led: For muTriple injection or nein -water sapply wells ONLY with the sane eanstrucdon, you can submit ane form. P 9. Total well depth below land surface: 3t 00 Fier multiple ivMs Use all depths ifdiigerem (example- 3W00' urrd 2@100. 10. Static water level below top of casing: 39 (ft) Ff tiler level is above casing, use " +" 11. Borehole diameter: 6 (in.) M Well construction method: air rotary (i.e. auger, rotary, cable, direct push, etc.) p.2 Ivor rtttemal Use ONLY: 14. WATER ZONES FROM TO DESCRTPIITON -G / ft ft is. OUTER CASING fur multi -cased galls) OR LINER if a lieable FROM TO DIAMETER TIFF ft `'1 16. INNER CASING OR TURTNG eothermal closed -loo FROM TO I DIAMETER THICKNESS -MATERIAL ft % in ft fG in. 17. SCREEN FROM TO DIA.IMETER SLOT SIZE TRICKNFSs MATERL LB ft. ft. fL Ill. GROUT FROM TO MATERIAL EMPLAC EPT \METHOD & AMOUNT fr. .O (et UNrt ft. ft. ft f6 19. SAND /GRAVEL PACK (iF lieable FROM TO MATERIAL L1rIPLACEMENT ENEMOD ft ft. ft ft. Z0. DRILLING LOG affaeh additional sheets if necessary) FROM I TO DESCRIMfON (color. hard- 06.-11/reck tTM Inin aiZe, eta ft, � � ft. 19.1 IzEft. fL ei 30o 'L S L ft % ft ft- A. fL 21. REMARKS 22. Ce Z-V ation: _ __ - /P /6 - &' - Stga n of Certifi ' ell Contractor Date t?v signing this form, I hemhy serf - that the wells) Mau (ere) constrtrcied in accordance with ISA NCAC 02 C.0100 ar 15A NCAC 02C. 0. 00 Well Canctruction Standards aad that a copy of they record has hem pravided to the well owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL 1NSTUCTIONS 24a. Far All Wells: Submit this form within 30 days of completion of well construction to the following: Divislon of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 276994617 24b. For Iniection Wells ONLY: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of we[] construction to the following; Division of water Resources, Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699 -1636 13a. Yield 24c. For Water Supply & Injection Wells: (gpm) Method of test: Also submit one copy of this form within 30 days ofcomplelion of t3b. Disinfection type: Amount: well construction to the county health department of the county cohere constructed. Form GW -1 North Carolina Department of Environment and Natural Resources- Division of Watcr Resources Revised August 2013