A24 104rt . �t
WELL PERMZT
Caswell-Chatham-I.ee-person Counties
DATE ZSSI)ED:��DATE DItILLEDa O�� vv CO
��R. ROAD/STREET:�
ADDRE55 s �.3ERMZT INZi I I 1 A
iIELL CONSTRUClION
Dystanee irom Souree of
D'istanee irom Neareat PropertY Lu° �—
Follution� ��ppl Statie tiater Level: M•
Total Depth' Ft. Yield: �M.
Zonu: �'�.��• �' -��-�
Water.Beazing - pyqmnter: �t lncbes
Casit�gs Depth: From,�_to_SL�- r/ �
TYPE: Steel Galvanizad Stael
If Steel. doas °�'� app=O�i a�eighs� ��o Inches
Meiqht: ?hicknesa: s,id�
Drive Shoa: Yas= NOi
tiere Problems Fa�Countered ia Sett � 4� Casang? Yea� M�
� '7es' give raason: �naete
Crouts �_ �at _�_ S� /Cementx -�—
l�aaular Space Width ��..Ine�es �
iiater ia 1►anular Spau: Yes�s� �1O po�d��
i�ethodz Ptu��d,�p�� �.
Depth: �am V LO 1,iniqht of
Matetials Useda No. Baqs Pozt]tad Ceaant
1 �8g l�• - Ratio: to
Ii mixture (san . avel. ecttinqs) �� �—
ZD Plates: Yes No�� �o=���t Yes��,�,��
4 z 4 slab Yes�.� No�.--
I�87 �ZFY SfiAT T!� 1180VE ZtiFORlSATIOH ZS GO
� SiiA? SliZS
itEyL iiAS COItS7RUCTED ZN ACCORDAK Z 7tE I.1lTIOtLS
FpR?H 8Y
C�yy��TF211lS-LEE-pERSON DZST. �
Sagaature of Con:ra Date
FOR HEALT1i DEPAR17iENT USE OHLY
IiEJ1SOH FCE 1�0 IILSPECTIDN:
Sanitarian's Sigaatcre Date
Sketeh vell loeation on.reversn side. Use established reEeseaee
poi.ats. •
� --� � The District Health Department
CASWELL - CHATHAM - LEE PERSON COUNTIES
,.Se L ^ C-�
�'�e $�'�' Water Supply and Sewage Disposal
%��, `��% IMPAOVEMENTS PERM� 1Jp,�_
U« Y �ae X -
/: � � ,, n '� Owner: _
l ��K Location:
� Contractor: �'»��
(� �
�1— r� WalO! Supplpi PllV8t@
� �.
Pubi��
Sewage Disposal Facilities: No. bedrooms Dishwasher� Disposal,
washing machine, other autom tic. appliances
: Size o! tank:�t��'� '' Nitriflcation line• �-3
� . Other disposal facility: �"� -.
' �Water supply; and: .sewage disposal facilities location, installation and
:• >protection" must ineet state and local regulations.
Septic tank should:be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health'Hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
' PROVED BY A 1VIEIVIBER OF THE DISTRICT�HEALTH DEPA,R,
STAFF BEFORE ANY POitTION OF THE INST LATION I COV-
• ERED AND PUT INTO USE. � w. T.�
�Date approved•
' Well•
Sewage Disposal•
By
Countera ����_ _ ��/%/ �
oigned— u�c�� �Qi
(Owner or his representative)
�
CerKScate o� . Co:nplelion '
Date Approved: � — � By• , . (�
S arian
�� • �R�
Location oi well and sewage disposai facilities sketched on back,
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Dec 2217 02:01 p Barnette Well Drillinglnc 336-598-9275 p.1
WELL CONSTRUCTION REC�RD {GVV-11
l. Well Cantractor iaformation:
b�f�rlZlAld � � T �L2.� �
Weli Contrac[or Name
�� a /�`
NC Well Contradrn Certification Number
Ba�nette Well Drilling, 1nc.
Company Nama ��
2. WeII Construc6on Permit #:
List aI: appfiro5le wefi consrr-.�ction pernrits fi.e. U(C. Ca�ty. Statz, Yaricnce. erc.J
3_ �Velt Iise ichecl�well use):
�V8iCi $UDDiY WC�I:
Agricultural � MunicipaUPubl ic �
Geothermal(KeatinglCoolingSuppl}•) x�ResidentialWaterSupply(singie)
[ndusTrial/Cocnmucial �Residential Water SuQply (shared) �
M1fon-Water Sapply
�Aquifer Recharge �Groundwater Remcdiazion
�Aquifer Storage and Recovery �Salinii� Barrier
�Aquifer Test [�Stormwater Drainage
�Exparirnental Technology [�Subsidence Control
�Geocherma] (Closed I,00p) ���
�Geochermal (Heating/CooEingRetum) �Other (explain unfler �21 Remarks)
4. Date Well{s) Completed: �� � 2`� 7 w'elt lAk �
5a. Wekf Loeatioa: � � , 1
-1� '�� ►��
Facilitg/Ownx Namc Fscility ID!i (ifapplicabte)
3/Z. !J'��e ,+�G � 1.� � �'o s�
Physicaf Addness4 City, a�d Zip �
� 2�0� ) �
County ?arcc! TclentiGcation No. (Y[N)
Use
tc. / p n- � � � �
fL � �C� fL �J��J¢- J
"ER CASING or murii�xed weA+ U
'rp D�AMETER
t�. rc g 1/s sa.
ft h.
� �.
RE'El�i
TO D
�, n
ft t�-
e. rr.
R. R-
[� ft.
lWGAAVE[. PAC
ro
ft. it.
tt fe.
Sb. Latitude aad [ongitude io degree4/minates/seconds or decimal degrees: ' —
(if wcl! field, one iat7ong is sufficitni) 22. Certl�Cation:
N �V �
�r—��a a
6.Is(aro) the N•ell(s) ermancnt ar �Temporary
7. [a this a repair to an ezistin� well: es or [�No
Ifthis rs a mpnir, fd! aue lo�own weel cvnstruction tnfor+naeion and explain rhe rwlvre of lhe
reFair wuler s2: mirrarks sectron vr on rhe 6ac'r of thb frum.
8. For Geoprobeli)PT or Qosed-Loop Ceothermal Welis having the same
construction, onLy 1 GW-1 is naeded. [ndicate TOTAL NUbiBEEt of wells
drilled: �� � � {� �e�P["�
9. i'otal well depth below land sue'face: ' � u� �;�-)
For multipfe weifs fist a!i deprhs rfJifjemru (example- 3Q:U0' and 2`a7,100')
10. Static.+•atcr level below top of casing= 25 (f�)
!f wa�erlevet �s abovc a:ting, use "+ "
red
�
r 2 � z �! �'
Daze
By signing lhis form, I hereby cetti�`y fhaf the wel!(.s wm (were) enns�n+ctad in aecurdance
wdh iS�I NCAC 0?C Af00 or 1:A NCAC: 0?G.0200 Welf Consr.�arat Stamlards a7d thn: a
copy o,Fthis reeordhas been provicfed !o thr well oK�n r.
i3. Site diagram ur additionak we113etals:
You may use the back of this page to provid additional well site details or well
consuuction derails. You may also attach addi ional pages if necessan�.
SUSMITi'AL IN�RLfC7'103v5
24a. For Il Wells: Submit this form
construction tn the follow�ing;
Division ofaaterResourccs, I
1617 Mail Service Ceater,
30 da��s ef cvmpletion of well
'on Proccssiag tinit,
NC 27699-[6i?
11. Borehote diameter. � C�n•} 24b. �or Injtction Wells: In addition to sen ing the forrn to �e address in 2da
Air rotary ahove, also submit one copy of this form wi in 30 da��s of completion oE w�ell
12. Well coastruetioo method: construction to the follewing:
{i.e. wger, rocary, cable, dimct pusl� etc)
Divisan af Water Resources, Undergrou d Injectioa Contrd Prograar,
�OR WATER SL�PLY �VELI.S ONLY: 1636 Mail Serviee Center, Ral igh. NC 27699-1636
13a. Yield (gpm) Z Q Metbod oftest• ��OWed 20 Mi�l. 24c. For R'atcr Saunlv IniecNon Wcils: In addition to sendmg the form to
the addscss(es} above, also submit onc cop oE this form within 3Q days of
t3b. ��neati� cy�• Chforine Amounr 1/4 CUp completion ot' wclE construction to the coua � health departmerrt of thc count}�
wherc constrticce+i.