WELL FINALHART 'T DEPARTMENT OF PUBLIC HEALTH RMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0672 -13 -0713 Parcel #: 04 0672 0004 02 Application #: 11- 5- 27536R Subdivision: SMB
Applicant Name: Michael Chisek
Address: 367 Sherman Lakes Dr
Type of Facility Served by Well: SFD
Sewage System: Manitee to 25% Reduction
Permit Conditions:
Lot #: 2
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 27 —1 `1- %.3
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)
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: (above finished grade) Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer: f
Sample Taken? ® Yes ❑ No Well Head properly sealed: e P
Remarks:
Authorized State Agent Date ALI
See Attachment for completion sketch
Application #:11- 5- 27536R Applicai une: Michael Chisek Subdivision: SMB Lot #: 2
Well Construction Sketch
Well Completion Sketch
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MAR- 07- 201t1(FRI) 13:3Q BILLS WELL DRILLING
WELL CONSTRUCTION RECORD
This limn can he used fix single or nndtiple wells
1. Well Cunlractur Information:
Michael Nanney
Well CnntrnctnrNome
346.7. -A
NC Well Contmetot Conificetion Number
Bill's Well Drilling Co. Inc.
Compaay Name
2. Well Construction Periull ik; 11- 5- 2:7:536R
List all uppilaitble well canmruction permits rt.e, Coun%State, Variance, etc.)
3. Well Use (check well use):
❑ASRicuhural
❑0cothermal (Hcating/Cooling Supply)
❑ Ind uslrittUCummercitd
❑Aquifer Recharge
IJAquifer Storage and Recovery
❑Aquifer Test
OF,xperimcntal Technology
130cuthertnal (Closed Loop)
❑Municipal /Public
JResidential Walcr Supply (single)
E3 Residential Water Supply (shared)
❑Groundwater Rcmcdiation
❑Sulinily Durricr
❑Stonnwater Drainage
❑Subsidence Control
❑ Tracer
4. Date Wells) Completed: 1-27 -14 Well TDp
5a. Well Location:
Michael & Andrea Chiselr
Facilitylowmer Nuw Facility IDII (11'applicubte)
2514 Matthews Mill Pond Rd, Angler, NC 27501
physical Address, City, and Zip
Harnett 0672 -13 -0713
county Pancl IdwitAostiun Nu. (FIN)
5b. Latitude and Longitude In degrees/mhlutes /seconds or deehnal degrees:
(if wall Gold, um Iaulung ie eufciont)
N
6. Is (are) the well(:.): f3Pernlanent or OTempornry
W
7.13 this a repair to an existing well: ❑Yea or ❑Nn
Foods Is a repair, fit out known well ennsnuetiml inja inatlon and ex)4api the nature o %die
repair under #21 lamarks.tection or on the bncA afthis form.
O. Nuinber of welts cniisirucled: 1
rue nrulliple injeclion or nun•wutersupply we/d 01V &I'nndi the seine aanrfruednn, you, can
Submit one form.
9. Total well depth below land 9urfoce: 145 (�)
rurmullipla wells 11114111 depihr Udiffirent (example- 3@21711' and 2@100')
10. Static water level below top of eosin`: +2 - Artesian Well (ft.)
lf'water level isahavecaling ore
11. Borehole diameter: .10
12. Well cunstruetiun method: Mud Rotary
(i.e. surer, rotary, cable, direct push, e(c.)
P. 001/001
For Inturnal Uee ONLY:
22. Certification:
_ 1 -27 -14
9ipnalure orcenided Well contnteto Date
by Signing this form, I hereby cenyy that the well( ?) was (even) ewerimicied In aecintkmee
with ISA JVCAC 020.0100 or ISA NrAC 02C.02170 fPrif Caitetructiniv Srmidardr and flier a
copy ofthid record has been proi,ldod is the well owner.
23. Slit dlogrant or additional well details:
You may use tho back of this pagc to provide additional well site details or well
construction details. You may also attach additional pages ifncoesi9ry.
SUBMT17TAT, TNSTUCTTONS
24s. Far All Wells: Submit this form within 30 days of eotmplction of well
construction to the following:
Division of Water Quality, Information Processing Unh,
1617 Mail Service Center, Raleigh, NC 276994/617
24b. A [ ie lion Wells: In uddition to sending the form to the address in 24a
ubuve, also submit a copy of this form within 30 days of completion of well
construction to the following.
Division et Water Ouality. Underground Injection Control Program,
FOR WATER SIIPPI.Y WF.1.1.4 ONT,Y: 1636 Mail Service Center, Raleigh. NC 27699 -1636
132. Yield (gpm) 60 Method of teat- Air 24c. For Water Sunnly .'z Tniectiun Wells. In addition lo sending the form to
the address(cs) above, also sub nit one copy of This form within 30 drys of
13b. Disinfection type: HTH Amount: 2 lbs completion or well construction to Ole county health department of the county
where constructed,
dorm GW.1 North Cnmlinn Depnnment nfpnvimnment and Natural Reeourcee — hiviaiop ofwoter Quality Revised Jan. 2011