New Well CompletionHARNVTT DEPARTMENT OF PUBLIC HEALTH "uRMIT
TO C STRUCT A DRINKING WATER SUPPL'. ELL
PIN #: 1507-38-6761 Parcel #: 1507-38-6761.006 Application #: 15-5-3691OR Subdivision: Walts Crossine
Applicant Name: Melvin Stewart &Brenda Mcneil
Address: 1451 _Red Hill Church RD Dunn N.C. 28334
Type of Facility Served by Well: DWMH
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 7
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 an Date
Gr mg Inspection Witnessed_ Date
Grouting self -certified by driller GW -1 provided? ZYes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name: 21&1,1-5
Address: _
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From _ To
From _ To _
From To
Inspector: _
Remarks:
Date Drilled: -Total Depth: _ Replacement Well? E]Yes [-]No
Top of Casing is _ in. above surface. Yield: gpm at _ ft.
Amount
Casine
From _ To
Diameter:
From To
Diameter:
From To
Diameter:
On Hold Date:
Material: _ Thickness:
Material: Thickness:
Material: Thickness:
Release Date:
Grout
From 0 To
Material: Method:
From _ To
Material: _ Method:
From To
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 d No Well Head properly sealed: V/
Remarks:
Authorized State A t /t Date
See Attachment for co tion sketch
Application #:15-5-3691 OR Applicant `-nie: Melvin Stewart & Brenda Mcneil Subdi- ion: Walts Crossing Lot #: 7
Well Construction Sketch
Well Completion Sketch
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