New Well CompletionBARN .'DEPARTMENT OF PUBLIC HEALTH Pc-AMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1519-06-3066.000 Parcel #: 071509 0062 12
Applicant Name: Signature Home Builders INC
Address: 1209 N Main St Lillington N.C. 27546
Type of Facility Served by Well: SFD
Sewage System: 25% Red
Permit Conditions:
Application #: 15-5-36726R Subdivision: _ Lot #:
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 AgdCZ)Z2�2
i
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 2'I4 -1% Application #: /5 =5-'3%�d.*ell 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 Preventers
Sample Taken? ❑ Yes
❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for comp(etib;( sketch
Date
z-1
Application #:15-5-36726R
Applicant -ie: Signature Home Builders Subdivision:
Well Completion Sketch
, nn nn.c.. 111,n9l.Urelr
Tbie Ih r 2 0. L L. C V I O or 4 : ] / r Ivi
tw mlerpd Use ONLY;
IV 0. 1 9 }- r. i
L Well Contractor Information:/�
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NC Well CoMMI Castigation N=Wr
N,W. Poole Well & Pump Co,
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2. Well Construction PermltN:
D��� 181 MAlYRI1L
h
R.
List all applicable ww0 ren a unisonpenntss p,e. Cow%, n, Fononn, ate)
h
1011
In
J. Wail Use (check well use):
to
WARIMWater
mount mit ass rsizz T61L10im MATrMAL
Supply Well:
DAgriculhmal OMunicipWPublic
I°'DGeodlcnad(Heating/Cooling
'la'
Supply) OR Identid Water Supply(single)
OlndusriallCommercial OResidential Water Supply(shared)MGM.f0
trA uePMrM'M oObrietion
90 IL
Celine en ro
Nati-Wale, Supply Well;
OMonitorin ORernvery
R
R
Injection Well:
R
(L
OAquifm Recharge OGroundwaler Remediation
,
OAquifer Storage end Recovery OSallnity Harder
OAquifer Test OStormwaser Drainage
OFxperimental Technology OSubsidence Control
,ROMR
M1 TO
14ATKWAL I MPLACRMRWMWF EMOD
R a
OOeothermel (Glossal Loop) 07YOW
OGeolhennal tHcaling400ling Rcrum) OOther Iain under 421 Rcmuke
Q a'3
TO
IL
D ON eWr buds edUrvk du ale
ITOJO
4. Date Well(s) Completed: a �� l t.
S.Well Location:
ul. If: �of� Weil ca
Peuliry/OyNwn/nerName II�� Fawity IDN (if apptieable)
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CCC
Ca ov
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Fr C (L 4 R
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dhysical Addrus.'City. and Zip
�I(ArINg4d-
Tde
a
( O� �� n'✓e
Conary Parcel Meetiscatim No. Mbl)
Sb, Latitude and Longitude In degreeelealnotedseeands or decimal degrees:
(if well field, ono ledlong is su®clonr)
350a3'(F,65' N -%8 NI? -3111 W
6. Is (are) The well(a): ( <Msneut or OTemporary
7. Is this a repair to an cetadng well: Over or ONO
If this a. repair, fail cut.btown well "Mlnietlon Infomwdon and explain she naNre Of&
,span under N2/ remark, section ar an the bane of thuJartn
B. Number of wells constructed: 1
For multiple Infection or tion-wmersupp/y wale ONLY with the saner mruovedo, K. nun
submit on,form, p,
9. Total well depth below laud surface: IO Y (R)
For mulllple wsla lut all deplN (rdlBerent (areuapie-1@2^00' and2®1001)
10. Static water level below top of casing: d D (FL)
if water level is above cosing, erre "�
11. Borehole diameter. (in,)
12. Well construction metho�O4Q�
(i.e. auger, eatery, auto, dumi pwb. em.)
13. FOR WATER SUPPLY WELLS ONLY: /�
13a. Yield (gpm)�Method of bar: P/01,V
13b, Dblakedon type; OV—T# Amount
22. Cerdflcst
Oi�dute oYGrtiaed Wed r Dew
By signing this form, I hereby vently that the will ,) vas (were) esaamvmd in a=,d,,,
wish I -M WAC 02C.0100 or ISA NCAC 02[.0200 Well Ceese eld-n Standard, and that o
copy gkhts mcordhee 6eenpmvtded to thevwil owner.
23. Site diagram or additional wall delulb:
You may use the back of (hie page R provide additional well site details or well
condructiun debits,, You may also attach addi(iond pages ifnxesamy
24. submittal Idarractions:
24s. For All Wella: Submit this form within 30 drys of completion of well
construction to the following,
Division of Water Quality, Infarmadon Processing Uuile
1617 Mati Service Center, Raielgh, NC 27699-1617
24h. For Infection Wells: N addition R sending the formto the address in 24s
show, alta submit a copy of this form within 30 days of completion of mall
Conshvction R the following:
Division of oterQuWy, Underground Injection Control Program,
1636 MAService Center, Raleigh, NC 27699-1636
24¢ En Water Sunak At Geothermal Wella: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction R the cowry health department of the comfy
where constructed.
Pont OW -1 Nonh C mfim Dcperlmoet olgovUonmaot and Neooal Ruomcu- DivinbO of Waur Quliw
Reviecd Jan. 2013