New Well CompletionHARM 'DEPARTMENT OF PUBLIC HEALTH P- 'MIT
TO CO,.STRUCT A DRINKING WATER SUPPLY _'LL
PIN #: Parcel #: Application #: 15-5-37133
Applicant Name: Randall & Abigail Dolinger
Address: 1185 South River Rd. Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: pump to 25 % Reduction
Permit Conditions: Well to be drilled in Well Area
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 re cation
Authorized State Age Date C 2 0 /J
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
NO 5
3,At33 WELL CERTIFICATE OF COMPLETION
(l "6.%1 % &Q �)u.l
Date: tohil,j Application#: 061c4 V' Well Contractor: �r jti�-meson
Applicant Name: A b f ; 1OoUa r
Address: t28q s R+�� 9-1• (.0c.� gad«u)
Directions to Site: _
SGS 6t�J-1
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: 1 (above finished grade) Access Port: ✓,.,� V..en�t Stack: _✓
Well ID Tag: ✓ v,'- Pump ID Tag: Sampling Tap:- -1 Backflow Preventer: _
Sample Taken? Yes ❑ No Well Head properly sealed: / rhi¢ d
Remarks:
Authorized State
See Attachment for completion sketch
CP C>f , 5
Date 1'7
2
Application #: 15-5-37133
Well Construction Sketch
Water
hole/Pond
Well Completion Sketch
Applicant' ne: Randall & Abigail Dolinger Subdi• 'on: Lot #:
Area for
Well
Building
50 ft.
Home
Septic and --�• ❑
pump tanks--► F]
Area for
Drain field
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WELL CONSTRUCTION RECORD
Tho foxm can be rand forsmgle or multple wells
1. Well Contractor InforImItim:
Roger W. Jackson
Well CanaimsmName
2179-A
NC Well COnhactor Cetificatino Numb.
Jackson Well Company
Company Name
2 Well Constrndfoe, Permit &
List all appocabk well penutr (L, Coaa1R SIe/e, pmimvee. IV a m, es,)
3. Weld Use (checkweB ase):
OAgiculhnml OMx®cipaupublic
OGeothamal(iteaimg/CouLng Supply) PRe.deo<ial Water Stirpply(smgla)
olodnatriaUCoomm:ial OResideacal Water Supply (shared)
OAgmfer Recharge
OGmundwalc Remediation
OAwifer Storage and Recovery
OSalmily Banner
OAguifer Teat
OStomwaterlkamage
OExper®ental Technology
OSubsidence Control
OGeothermal (Closed I oop)
OTracer
Membermal!Hestina/Cooling Reame)
O(aher leanlain ,order 1 R
4. Date wdl(s) Completed: %,9- OW we9nw
Fe hormion Um Cft&y
rs W.I META=M-M-IrmE�
&P—/? hr /T e 6-7-2-sz -j-m r
County Psxeelldwlificauon No. (P@
5b. Isdmde and Longitude in degneestm nmes/seeonds or decimal degrees:
(i'fvan &field, one 1&010% s suffcie2) 2L
SJ 6OC / �d I N�W
6. IS(—)the welksx MrEinzanem or OTemporaay
7. Is this a repair to an existing well: OYes or
Ifdus n a repainfin out bawr w Mmmeteum mlo teamia mweWl®r dw minor ofam
repmr order 02I mmarls aecdm or m 8a back oJjOtlsfosm.
& Number ofweUs eons4vt3ed: /
Formddpfe vgectiwlarnoo-somrapply weds ONLfwith da, ameeonabrrxtioa, ym cunt
mbtut sae form
9. Total well dearth below hind mdaee: (8)
Farmddpk wells lase a0depdaif&ft,, a(eneapk_3 00'mrd2@100)
10. Static water level below top ofeashig. y!J (R)
lfw krk en is above miring, me "+"
11. Borehole diameter. lali—(m)
12. Well eoa iruetim method: / /7 Wr/iff (
(i.c evge; mtary, ®bk, dvatpasl; Uc.) �
R I R
R I R
RI R
�1 a aII'7
MMM
ft I R
ft i rt.
R R
>7 i
By -gin das john I hereby sniff drag da »e0(s) war (sere) comtrucied b aaords,.
.Uh 15A NCAC 020.0100 or 15A NCAC 02C A200 WeR Cmmucexvr 5 mdards and cunt a
copy ofdms nxcordhasbeea prm z*dW da well w ,.
23. Site diagram or addrdmad well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also anacx additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a For All Wells: Submit this form within 30 days of completum of well
construction to the following:
Drva®on of Water Resources, Information Prooesdrng Una,
1617 Mail Service Center, Raleigh, NC 27699-1617
74h For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this foam within 30 days of completion of well
construction to the following
Division of Water Resources, Underground Injection Cmta AProgram,
FOR WATER SUFFLY WEE" ONLY: 1636 NUB Seavfce Center, Raleigh, NC 27699-1636
r
13a Yield (gpm) Method of teat:24e. For Water Supply & inleation Wells:
%
Also submit one copy of this form within 30 days of completion of
13b. Disipferman type Ammunt: well construction to the county health department of the county where
contracted—
Form GW -1 Nath Caroline Depamaa ofEmammem aid Nenaal Resources- DinImofWamr Resources PwIWAIV=7,013