New Well CompletionHART' T DEPARTMENT OF PUBLIC HEALTH RMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0634-07-5873.000 Parcel #: 050624006601 Application #: 15-5-35847 Subdivision:
Applicant Name: Charles & Kathy Moore
Address: 38 Chalybeate RD F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
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�� Date 1" —6 --IS
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
15" -5�—
Date: Application #: 3 S ki Well Contractor: 4,0% RtIGSa.—
Applicant Name: C4,4. t< �p�lr /{arae,
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)
Casine
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: Pury{ ID Tag: Sampling Tap: / Backflow Preventer:
❑
Sample Taken? Yes Nd: ✓o Well Head properly seale_
Remarks:
Authorized State AgetQ'!� Z 11 /A'Jl4em� Date
See Attachment for completion sketch
Application #:15-5-35347 Applican me: Charles &Kathy Moore Subdivision:. _ Lot #: t
Well Construction Sketch
T n
r
� J
sem'
Sti a t` -A
J
Well Completion Sketch
I
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Roger W. Jackson
Well Contractor Name
2179-A
NC Well Contractor Certification bloater
Jackson Well Company
Company Name �j�,�..t� 7
2. Wen Construction Permit
q: �IJVI'ri2 �J
Litt afl applicable well permits (.e. any. State, trariamce, Injection, em.J
3. Well Use (check well use):
❑Agricultural FIMunici al/Public
OGeothermal (Heating/Cooling Supply) tial Water Supply (single)
Ohidustrial/Commercial OResidential Water Supply (shared)
Non -Water
OAquifer Recharge
OGroundwater Remediation
OAquifer Storage and Recovery
OSalinity Barrer
OAquifer Test
OSormwater Drainage
OExperimental Technology
OSubsidence Control
OGeothermal (Closed Loop)
OTmcer
OCe flwrmal (Heatine/Cooline Return)
DOther (exulain under #21 F
4. Date Wen(s) Completed: AAAA&:Wen
So. Wen Lara}�'on:
Facility/Owner Name '7Facility ID#(if applicable)
Physical Address, Cay, and p
County Parcel Identfcation No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Wong is sufficient)
6. Is (are) the wen(s): 2WVQnent or OTemporary
7. Is this a repair to an existing well: Oyes or
Ifein's it a repair, fill out known well carrion cdon information and explain the nature afthe
repair under #21 remarks section or an the back ofthajorm.
& Number of wells constructed: /
For multiple irgection or non -wafer supply wells ONLY with the same construction, you can
submit one form
For Internal Use ONLY.
/.zL`t- /3'rIL /d7s+ft- /3'rIL /d7s+,
I ft I it I in + I I
ft ft n
I `tl RI ml I I
ft
it I it
ft 1 ft
Aft > rt
ft f.
ft If.
ft ft
IL ft
22. Cekiin 1dam % y
Si&mffreof GerfifiedAFell Contractor Date
By signing this famn, I hereby certify that the w fl(s) was (were) con iracted in ae rorderee
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constriction Standards and that a
copy offins ,card has been provided 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.
/y� SUBMITTAL INSTUCfIONS
9. Total well depth below land surface: oW ✓ ([L) 24a. For AB Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ifdlfjerent (example- 3®200' and 2(x)100) construction tothe following:
10. Static water level below top of rasing: ��! (B.) Division of Water Resources, Information Processing Unit,
If water level is above cashhg, use "+"�� 1617 Man Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: �—(m.) 24b. For Inksetion 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 well
12. WeB construction method: construction to the following:
(i e. auger, rotary, cable, direct push, etc.
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY JWjELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Ou Method of test: 24c. For Water Supply & Injection Wells:
/ Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount >b well construction to the county health department of the county where
constructed.
Form GW -1 North Carolina Department ofEnvvonment and Natural Resources- Division of Water Resmrces Rev iced August 2013