WELL COMPLETIONHARNF DEPARTMENT OF PUBLIC HEALTH PT 'IIT
TO CONoTRUCT A DRINKING WATER SUPPLY h ,,,LL
PIN #: 0682-81-8721.000 Parcel #: 04 0682 6024 Application #: 11-5-27451 Subdivision: Pointers Creek
Applicant Name: David M Byrd & Pamela L Byrd
Address: 17 Ouarterpole, Warrenton, VA 20186
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 3
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 A
61
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date:'-(#' 1< Application #: I 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
Grout
From To
From 0 To
Diameter: Material: Thickness:
Material: Method:
From To
From To
Diameter: Material: Thickness:
Material: Method:
From To
From To
Diameter: Material: Thickness:
Material: Method:
On Hold Date: Release Date:
Well Head Information
Casin Height- ght:
(above finished grade) Access Port: V nt Stack:
Well ID Tag: / Pu D Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes No Well Head properly sealed:
Remarks:
Authorized State Ag nt Z /11 ' Date 'C �v / b✓
See Attachment for com etion sketch
Application #:11-5-27451 Applicant ie: David M Byrd& Pamela L Byrd Subdi n: Pointers Creek Lot #: 3
Well Construction Sketch
Well Completion Sketch
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