Loading...
A26 75;a� �c�3�3� �' ���• � "a�- � 6 �.--- �������0 7_"'_'� ��C�o� crs � I�� �.-...- �.�1 I� Z ..�.----- .�_...------ ?} ��Ps����. �D�'���•`�r�s-� �'�,�c i.c� � �:�� s�hane ���: -.�oL� (u�r� a � I�C�t�S� �!? f't �.l�i ��i �e:�7:n �r=t ' i n �fi2n �'r'r f � ?�{7 �� �— L t�'Es��7 �kt' F���' e,,"�',.#t'� ���3�.....��_ �� T��� � 2��as"� sa�� P�lUf1� �rame; � . � d.�r�ss: C. 2? �i sa• T�'iZ� �II�L��FSIDs'!: �} ?: o�e� ��..��.Q_. Lo' ..�...�--- Mo r � �dci���s andlor di�e�tio�s ta �'r�P� � � �3 �.Q ���$,.L.. w.ia C� g��t3�i5{i1S�'CtUsiat tr+:ucsu.+... tlw oiw j� ye,S II IItt �Qe�-�.e sLte �aII��Y �g �'IasieW3�T sJSt�n75 � � B IIo Is �y ������r �nzngto �E �nerat�d an �a �it� o�.her t�aa o II y� II no isti�e siie sub3ectifl approY�t �Y �Y o��T���c a�en�'? p pes II ao �ra ti�ere auy �semet�s orr�rt �4va� ����m.e�.) C�tses' is absdted, l�eas� �vid� �a� ^ #�s � � �L�i-�: t } �y£l3��E�%'� �� 3�?� s� � . Q�estaers�I i�.imtr� num�yer nfb�dr�om�: ._._-- � i�Ie�;� Sinaie Fami� Re�d�tce ���� C� �er or"I�edrocrms. C� E;cnansion ai�� �Y� I�iil �terabE aba5� II Y� �: no '�1 C1 R.�pa� bo it�alfuac�nm� �Y� Cl�d�� ��e��a� �'p� Scjuara iflat�� fype o�isus�.r�s: 11.[2��m ntt�►b� � IIlt�i� Q����� tivelI Q E��iing �elI 1� �amm.r�L'nxi.Y i�iFe1I � Fvbli .. A �- E".�' 1�%w n . sZ �r��..� ���_� ��ere affy���aelis= sA��: o� �is�n���rti�s or�f �} a � �r„3�l�"�3� �� ¢��F'���33 fQ �?�a5�a'�"a ��� }���'��"'�'-=��� � Cont►enfzonal II Accepteci II�novative Cf Aii��ve i� O�r — e .� � avir�ed abov� is r.a��Iete u�d ccr�e� 1 dlsa �a ; ��.�j, �1�at tFie u�or�nafio��u' r.� uz u isule�'ctt� c�' �� s�e �s s�ec�rae�ly uire�r�, or ihe ir�ie�d��-� c��a�,�s a: �� "`�, - _ - d M �pporl��s�cnm�.tin�r�� . ^ � �- �tt� ��' �-�v:sS��a����g�`��� ��� �.�� i�" �,�g � � a.s���..,� � ����t � ;.��p� .���F� CE1�L�0.00 ���� Gv � d�� � / � �� --- '` Lin4 i��a �i '.1,; II I� ;;_ ; o�bniit� - ,, 1 S�LSf�: � } �T^��8� Q �`� 5 p�� g y� II na a i, � � �F ;� ���;� ; � � tm�il�tF �'t�2 ��°��°�ided i� � � ��.�yaj,� gj� b2 itivctlltl , i; 3j�28-1(a ; ; �� � � � � �p����� ��� � • �� � ;�'���i�'� _._ ___ _..., .�r.r WELL CONSTRUGTION REGORD This form can bc uscd far sioglc ar miltiple wcllz 1. Wdl Contractor informa6oa: a N`lr�' �`'e Lf; �Q,�� 7�}'" w�u oa�� N.,,K 3�?���1 NC Wd1 Coatractnr CudCkation NumUa Sarnette Well Drilting, Inc. �auy Namc 2. �'4rdl Coasiractiou Pvmit tt: List a!! applltnbk wc/[ conrt�aaion pernfiu f.c Cnvouy, SratG ['anonce, acJ �. wd� vx ��n�.�du ���: an��a� nM�����ur�,t���- oGeothamal (Elcati�g�Cooling SuPdY) � dcndal Watrr SuPPiY (�Bt�) �InduShiallGbmmcrcial ORaidenuat Watu Supply (s6ared) xoa-w=� supp�y wa�: �AquiEcr Ra��arge OGmtuidwattr Reiiicdiatiun �Aqtiifdr Stoiage and Rxovcly OSalinity Bartia OAquifcr'I'esc DSiormwat�r Dcaivage DExpaimentat `Cechnology �Su6sidence Contml �C�ttha'mal (Ciostd L.00p) Oltaca QGootherina! fHratinr/Cool"me Kih�inl �thhtr (eimlaiu auda tF2t E � Date We[t(s) Complctcd: ��� We11iD# Sa. Wdl LoeaCiaa: �l�ll �G1 r r � . FacifitylQwnG Nauia Faa�cg ID# (ifiipplficatik) Physical!4ddcess. ��Y. aud ZiP ' �C�SD h �:ounty Pamcl IdmoifiadiouNo. (1'IM 56. Lsfifnde and Longifadc ia.degrtcs/mi�tptes/sct0udsar dedma[ ikgraS (fwtU �dd. ooe laNmg is saffipiwt) ' .. 36-z6 �Z N 79 GZ-�7 � �'Is(mre)thcv0'sll(sj: 9i"�etmanen� or �'I'emporary . ' 7_ is this�a repai� W aa n�dslipg.wdl_ H'la or ONo Ifdds b u iepatr, f!1 our+browrvd! aonrripaion i�Oruratta+m. darplcin rhe �anatoJdra +rpair+�erC2l rr�xseufonaroefhc.6x4ofdrlsform. 8.:Nami�erof�veUsconshvcted; l�/1i �(PCy. C9-tC���%� Formultq�leiyacrionornoa-wattrsry�dyrellsONLYwith!/tuwre yvuam s�dirrtrro�rejarm. 9. Tutai ive4t do¢tfi btlos� liud sodace: Z V O � ((t) �For andr`p1d wells lirtoll depths ijdrffererit f�mple-3�Ioo•andz�(OlJ') 20. Stafic rvater tcvet bduve top oLasiag: Z' � (�) ff wa[erleiW a above arsFn� +de +' �,e, i jje�-. ���e'�- v0' �o Zeo' Fa i�t ux ort[.v_ , (�tU c.o�S�� � « Z'° n- �� �Q rc � rc ��q.l :Oit[E1� �CASQ'JG forjnaltiratii tir .pM 'CO DCAMEIt�II � �. � _ :�a�►ve�r � ot�:�roeirrc: ',OM � TO DLU1tE[ER R. R. �- tc h � _ :scnE�+t; : ... :.:...::::. ._�:..: �_::...:. �; �OM TO OiAFtEIER SL R f� � a � � _cico!u-r :OM TO � MA17.RIAI.�-.� 0 rc Gp rc ndl� rt � R ft � :SAND/�:IL['YE�pA YC _ >I'YsMe i :oM ro Mw'r0t4u. tc tc. tt R [f. t R r, ?.�. CeY�tificaHon: � ����' ' ! �- 2 g --�6 ���� �� SigoauvaofCaSfia► We1L Comrat�or ��: ECi' signHS�tr�ar++. i 1�erebi' «�r�y' dxu +Lc welt fsJ �cs (xenl wnrr'ryded Br awordax,a _ vlilrlSd'IYCtC 62C.O100 cr lS�f NCRC OIG.QI00 Wclf Cores7irdcduhSYaiid�ails mrd dW(a �FY'9{rkfr {eaordiasbab�lrcvided�a d+e �re!l o�vaer. ?3.5itb'd'irgtim br f[ddi�od9lwdl d�s: YW► m�y usb d� �adt of tbis (�e i4 �ovidc: aailitiata7 we{f. sitc defa�ls Cr aell � ddai'ls. Yon majr atsG.at�achaddititicial pages if ncetssaiy. SUSM[�'CAL.INSf [TCI'IONS 24a. For Ail W.dlx Submif this �£atn wn�hin 30 days of c«nplefibki of wdt cdn:wucti� [tit6efotlowiitg: Aivision of WatcrQaaGtg, Informatioa.Processiog Uai4 16171Kai1 Serviae Ccatcr, Iie]ag�,1�C �699�-1b17 11. Borehot� diaiueter. 6 f a:) 246. ;�or ldiectioe� VKdIs: in ydditim to sading thb fotm W the addioss in 24a n above, atto subrmE g o�gy af d►is foad withiii.30 days of compldiar of+tiell 12. Well eoosh-uction met4ad:. �(�,�,, 1�- ��'� %Z t� �q�ion to the follow� C�� a� :�Y. cabb: dica�i P�. �-) Div[siod e[ Witsr Qsality,. Undergraaad. [njeetion Coalsd Ptognm, FOR.WATER SUPPLY R'ELiS ONLY: i4i611fa7.Saviac Ctatcr, Ralr�h, NC 27699=1636 13: Yidd m. �� Mefhod of`ta� Blown20 minute ��ariYater.SabMv & Iniecliou �d1� In addition to saiding the fbr�n to (SP � tha ad�iess(es) above; aLso subu►it ot� eopq of. thu foiin witfrin 30 days of 136. Disinfeetioa typ�: HTH �lmoant '��Z CiUi� c�pidiai o€ wdI cw�s6ruction f+o the cuuiify hcaltli dq�actii�ad of the cauiey vuhrre coris6ifti�ad. Fam GW-I Nwth Ce�otiaa Dcpat6uestafFnvimdomt aad Naaral Resoaoss—Div'aion of Wa�uQiiaGry RevisedJan 2013 Tax Map: �� Subdivision: ���.sf ������ - � � ���� IE�rawn�r�aa�cam�ra'dmIl g�ao�Il¢Ila Parcel: �� WELL PE�T /� (New _ Repair ) L 1►'�� Lot: Applicant's Name: ���r'� l'��f k�r% l� �b W� d�' ���a�S' Mailing Address: Phone Numbers: Location of Property: � 3�P d� �'iDr �}-o,, �i.(ll� a.� �c.�� Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and Cor�rtty regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: �New Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comrrtents: Date Sample Collected: EHS: � Certificate of Completion �Li�.e.r� �drilit de.c.��¢r) Z�Gt 0 Y � Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date: �� iner: EHS/Date Depth: �p' Grout: �� -� � DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13