New Well CompletionHARN r DEPARTMENT OF PUBLIC HEALTH ; tMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0665-13-1146 Parcel #: 08 0665 0001 Application #: 15-5-36930 Subdivision: Lot #:
Applicant Name: Stephenson Builders
Address: Angier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: 25% Red
Permit Conditions:
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 Ag t Date 1-- if—,( 5
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)
Casin¢
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:
Sample Taken? ❑ Yes
❑ No Well Head properly sealed:
Remarks:
Authorized State Agent
v
Y
Date
See Attachment for completion sketch
Application #:15-5-36930 Applicant! ae: Stephenson Builders Subdivision: _ _ Lot #:
Well Completion Sketch
Nov.20. 2015 9:56AM
mum. LU115I ItUL 110N RECORD
Thi. fm.. b. meal foe elnglo or uzwov a a.11,
1. Well Covrrectur Information:/I
FI° 1� y4cob�
Well Contractor Norse
r� r
-T (3 5- �(1F \
NC Well Conoac(m Cuu&aAan Number
N.W. Poole Well & Pump Co.
Compcay Nome f�/p /f
2. Well Construction P<rmlf N: � ,j^ � 1 O 0
LiP allapplimble wdr conrnucrlan permba B. I. Cowry. Seta, Ya ammo)
3. Well Use (check well use):
OAgriculluml OMunlcipal/publio
OOeothermal(Hesung/Cooling Supply) =151denual Water Supply (single)
Obidustsie17Commercial OAesidenual Water Supply (shared)
OAquifer Recharge
OGrowdusta Rcmcdlation
OAquifer Storage and Recovery
OSWIPIty Barrier
OAqulfer Test
OStormunum Drainage
OExperimentsl Technology
OSubsidenco Control
OGcothcanal(Closed Loop)
OTMOK
4. Date W ell(s) Completed: ��y ,
lawroil Use ONLY!
R I U? ? fn I I_ Io,
RI R
RI R
MK=
rlx�
f. I ft,
R 1 0A R
1 Well Location! / R R
IAifkinS R R
FeeilirylOwner Name Facility me(if apphosblo)� ft. I M1
Physical Addrem, City, and 2iAJ V
-&mo+
County Parcel Identification No. (PDt)
Sb. Latitude sad Imagltede In dcgnd/mihutule<eovde or decimal degrees:
(if.ve0 held, ane levioop is fWSoloop ^7p I� ll'I 2
c , rN lQp]'`Yf J�• I�ft W
6. Is (are) the wtll(s): O ermencat or OTemporary
7. Is this a repair to on relating well! Oyes or ONo
!f this is a repair fill ou knb wait conelrudion or om,arinn coed uplain the mouse of the
reposr under sL remark, section or on the back of the form,
8. Number of wells constructed: f
For multiple infection or nomworer supply works ONLYwah rhe enea ew Fm coon, )oar can
submn one farm.
9. Total well depth below land surface: (fL)
For mulstpl<.v/ls Ips ah rkptlu%d rent (esamr,le-IG00'md2®100')
10. Slsfie water level bdoa top a(caelvg: .-!_D (ft)
1/Ware, level4 above rasing, use "i"
17. Borehole dlantet<r: /�0_ (.Ie,./)
12. Well construction method:
6... super, return cable, direct push etc.)
22.
f,
o. 0821.—P.
Du�
By slrlog rhls form, f hereby a,llfy that the w il(j) wm (wprci eontnuded in o tordance
wnh 13A NCAC 02C.0100 or ISA NCAC 0X .0100 d'BI Constrsmon Standard, and that a
copy of tho record has been provided to the well owner.
23. Silt diagram or additlooal well delalb:
You may use the beck of [his page to provide additional well site details or well
coostmction details., You may also attach additional pages if necessary.
24. Submittal Instructions:
248. For. All Rdls: Submit this form within 30 days of completion of Weil
wristruetion to the following.
Dividam of Weler Quality, Information Processing Volt,
1617 &fall Service Center, Raleigh, NC 27699-1617
24b. For 1 !eaten W e: In addition to sending the form to the address in 24a
above, also submit a copy of (nip form within 30 days if completion of well
construction to the following:
Division of W der Quality, Underground Infection Control Program,
13, FOR WATER SUPPLY WELLS ONLY: 1636 &tall Service Center, Raleigh, NC 27699.1616
138.19dd (gpm) &Iethod of seal: IO (/ t' 24c For Waler Suooly & Geothermal Wells: In addition to sending theform to
the address(ra) above, also submit one copy of this form within 30 days of
13b. Dislofection ypa Amouah completion of well construction to the cowry health department of the cowry
Wdsac wnsWcled,
Fane OW -1 Nanh Caroline Depu®ea ofEm9onmeat rad Nsnael Reeoumm- Divuiae ofWebr Qudiy Rrneed 1m, 2013