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New Well Completion PermitHARNF 'DEPARTMENT OF PUBLIC HEALTH -MIT TO C(,- oTRUCT A DRINKING WATER SUPPLY ALL PIN #: 1610-87-9473.000 Parcel #: Application #: 15-5-35299RR Subdivision: Applicant Name: Martin H Yde Address: Type of Facility Served by Well: SFD Sewage System: 25% Reduction Permit Conditions: 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 Agwl=� Ami6v44 Date I Grouting Inspection "Wiit/fuesssed Date ❑ Grouting self -certified by driller GW -1 provided? [:]Yes ❑ No See attachment for construction sketch WELL CERTIFICATE OF COMPLETION Date: 3 -t 04 G Application #: 361lw" Well Contractor: 1 ' 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: I(above finished grade)/ Access Port: / , Vent Stack: Well ID Tag: Puump�iiID Tag: Sampling Tap: / Backflow Preventer: Sample Taken?E] ��No Well Head properly sealed: Remarks: / Authorized State Age Date �+')y %tv See Attachment for complet n sketch Application #:15-5-35299RR Well Construction Sketch Applicant' ie: Martin H Yde Subdivision: - of #: Well Completion Sketch it D b � LA, -1. (�r-V, (Lt's From:Harnett Ca Planning Mar 10 1603:13p Strickland Farms, Inc. 910 893 2793 03/11/2016 09:10 (910)594-0034 0204 P.001/001 P.1 WELL CONSTRUCTION RECORD 13ds fonneoa 1e w.d hs singe or mWtiple wally L Well Contrsesor Inrormstion: 1(N�Irn •IL�K"�ay For IN<mallhe ONLY: '.. fAOM •10 DEtW9r10N well Comrmwe/None -ll°17 7- NCWnCoMawrcooi6retimNomaer F �p ,,,/ fJd9/P C{ -4 V-L�/L//i��sy/� `) n' ^(-yc �/' /r�C `. ISOU2ER CASING fvmdfioiid wear OR LIfaFR if -bMe -:- .' FROM TD D/UMSIER TNICIJiFSs MA'ITAIAL 0 n. C/V R G'/ti s"' Yri�ll C."..'Nems 2, Well Construction Permll d: 9Z 77 Lze a!1 appl¢able vxll pemda O.e. Ca..T. leant, Vana., I Keriwr, ued 3. Well Use (.beck well sue): 1& INNER CASING OA 7.OBING: wmeimel dmrd-Ira : i. :-- _ }ROM yD DNMDrtA TanOgliSa MAIUTAL .__.fi '.- R In fl. R in. 12: SCREEN '.:.. %V.1"Supply Well: OAgri<ulmral DM��WIic�agPublic OGmth<rmal(Reatil jCooling Supply) CQRts�dtntiel Wsler Supply(singla) OlodushiaUConsmemial ORaidential Water Supply (shared) Olnirmlion mom /b o slartslzs tRICKN -. ..... fr. -n. in n. n. in. /PDMROUr 10 MAMKL IGIPLACfatWTMLTNDna ANOMT B. a. u/ //Je. N %sL✓,. / NO.Warer Supply Well: OMoniloring DRecavery &I R i Iojeetioo Well: DAquifer Recharge DGrotmdwuler Remediation OAquifu Slowe and Reewary DSollnity Barrier OAquiter Test OStmmwvamr Drainage OFxperuoenul Techcmingy DSubsidence Coastal ❑Geothermal (Closed loop) DTraeer DGeoNermal(Heali Cooh Ratwn) 301her(mylainuodefg2f R emarks) it. D. -19.5AND/DJIAVCLPACRirn lathe fRON loo I MA ML RNiuCENdrTM UD 0. 20. DRILLING lOG focusch Wtli6ominhkrD Laacesa WDN) 1D DLSOumon rarrtwaara.ahw can aL acs 0 n' ;/ K -SCyn : / i' d. DoleW'eEi(s) Completed: � X25 - i6 Wag fDN Sa. Well La,cls ion: a ll.i/7! r�r 1t FZ:if Dwaer Nays: _ n Fatiliry ID4'(dapplimbW n. fa h +, PhysiolAodms, Cay, mditip Pctro Cowry Perm) IdWA&MtiW No. (PIN) 5b. Latifude and Longitude in dcgseedneinuleslscovads or decimal degreev. (if well field, ane las o t, is su(GcienO W 6. Ie (are) the we0(r): ©Pirmsosal or OTemporary 7. 1. this a repair to an existing .,It: Oyer or Dtsla� rfthu a a rcprir, fill oat lnoern ve11 emzrrvenan ,nfom,ociw ondeaylaw rhe sonic side repro .+ ,, a21 r<moHn reed. yr ..,h. hor,1k ofdarfwm. 8. Number of wells coONtucked: N Fa wNap)e mJrdion wnm.uamrzupplveralr ONLrnith the moreomeftedo . yov con .obmu onrf. _i. 9. Tohlweg deplb below hod surface: For or, all d,* ldoenar fuonplr- 34200' cod 2®100) ]O. Slade anter level below fop of wing^ 1127 Ifamar 1c 1 14.1t. a emag nor "l - 11. •l -11. Borebole diameter: /10 (in.) 12. Well contraction melbod: A,94cril e. mg0, army, oak diem push, ac) R I R. ?IL.REMAAKS:: - -7 2L Car7iRnuyp� / IMr fdfw, I hardy eetnyy chat the ewll(q vaz (c) mMwned m orr9ndanrr CACO217.0I01) n• ISR NUC 020.0200 Wr0 Cwovaeem Sewdo and lhar a accord hon DernPmoidedm dee xdl master. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details of we) l construction details. You may also attach additional pages if necessary 244 For All Wells: Submit this form within 30 days of completion of well cantnvaien to the following: Division of Water Resources, laformation Proeesisb Unit, 1617 Mad 5aviee Center, Raleigh, NC 27699.1617 240. For Iniedion Wells ONLY: 1, addition to sending the form to tx address in 24a above, also submit a copy of this form Within 30 days of completion of wall comenadion to the following Division oftaster Resmrcm Uedetgromd Injection Control Program, FOR WATER SUPPLY WELLS ONLY: /1636 Mail Service Center, Raleigh, NC 27699-1636 Da. Yield (gpm) ^( /J Method of fait /' La For Hater Supnh, & Iniecdoa Weds: Also submit one copy of this fops within 30 days of completion of I3h. DisipfeeNoa gyps: ! hof I cv`p Amount:?o: f well construction to Ne county health department of the county where conslica led. Fano OW -1 Ho corolineDcpunmem of Ex"mnmcui ant Nasal Remnmas-Divizion ofWaml Ramses Rnicel A.W.1201-,