Well CompletionHARNE )EPARTMENT OF PUBLIC HEALTH P1 IIT
TO CONo ERUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-35336 Subdivision: _ Lot #: 26
Applicant Name: Barry Elliott
Address: 90 Pit Rd. Erwin, NC 28339
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Well to be drilled in Well Area
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 Agent J /�,.(,� et /ff Date ? °fir
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -I 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)
Casine
Grout
From
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From 0 To
From _
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Diameter:
Material: _
Thickness:
Material:
Method:
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Inspector:
On Hold Date:
Release Date:
Remarks:
Well Head Information
Casing Height (above finished grade) Access Port: Vent Stack:
Well ID Tag: PumUlD Tag: ✓ Sampling Tap: ✓ Backflow Preventer.
Sample Taken? ❑ Yes No Well Head properly sealed:
Remarks: Q
Authorized State Ag G DDaate 7 --/z — 17
See Attachment for comp] tion sketch ' /
Application #:15-5-35336 Applicant 1, : Barry Elliott Subdivision: : #: 26
Well Construction Sketch
Well Completion Sketch
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SUBMITTAL INSTUC
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FOR WATER SOPPL WELLS Omy: 1636 Mail S
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