WI0700308_Suporting document_20210730

Injection Facility Insp. Report (Rev. Sept 2009) Page 1 of 4 Pages

North Carolina Department of Environment and Natural Resources
Division of Water Quality – Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI0700308
DATE OF INSPECTION: _7/30/21_
INSPECTOR: ____R. Sipe _______________
NAME OF PERMITTEE(S) Timothy & Laural Washburn
MAILING ADDRESS OF PERMITTEE 518 Hollywood Blvd., Havelock, NC 28532
PHYSICAL ADDRESS OF SITE (if different than above) Same as above
PERSON MET WITH ON-SITE Timothy Washburn; TELE NO. [phone]
WELL(S) STATUS:
__X__Existing and operating Class V Well
_____Existing well proposed to be converted to Class V well
_____Proposed/not constructed
LAT/LONG OF WELL(S) (no change since last inspection)
Appx. distance of well to property boundaries: _20 feet (Inj. Well)_____________________________
Appx. distance of well from foundation of house/structure: _32 feet (Inj. Well)___________________
Appx. distance of well from septic tank/field (if present): _N/A____________________
Appx. distance of well to other well(s) (if present): __160 feet to supply well _________________
Appx. distance to other sources of pollution: _None________________________________________
Flooding Potential of Site: ___high ____moderate __X__low

Comments: Both inj., and supply wells appear to be in adequate structural condition.

See Attached Map

Injection Facility Insp. Report (Rev. Sept 2009) Page 2 of 4 Pages

See attached Map

DRAW SKETCH OF SITE ABOVE (Show property bound aries, buildings, other wells, septic tanks/drain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow )
GW-1 forms attached.

____________________________________________________________________________________________
Draw Schematic of well above showing TD, casing depth, grout, etc.

Injection Facility Insp. Report (Rev. Sept 2009) Page 3 of 4 Pages

Well Construction Information

Date Constructed: __12/4/2012__________________
Well Contracting Company: _Applied Resource Management, P.C.______________________________
Well Driller Name: __Donald Cummings____________________________________
NC Well Cert. No.: _2412-A_________
Address:_257 Transfer Station Rd., Hampstead, NC 28443___________________
Telephone No.: _(910)270-2919_____________; Cell No.: ______________________
Email Address: _________________________
Proposed Depth of Well(s): _N/A___________________
Total Depth: __165 feet________ Total Depth of Source Well, if present:_165 feet_____

Casing:
Depth: 135 feet; Diameter: __4 inches_; Type (gav. steel, PVC, etc.): _PVC___; Stick Up: _1.5 feet____ft

Grout:
Depth: 125 feet; Type (cement, bentonite, etc.):_bentonite ; Placement (pumping, press. etc.): _poured. .

Well ID Plate Present (Y or N): __N___; Heat Pump ID plate present (Y or N): __N____

Influent spigot (Y or N): ___Y_____ ; Effluent spigot (Y or N): ____Y_____

Well Sampled? (Y or N): ____Y___; If Yes, Lab Sample ID numbers: Influent and Effluent___

Static Water Level: __11 feet (at installation)______

Injection Information (if applicable):
Injection Rate: _______________GPM
Injection Pressure: ____________PSI
Injection Volume: ____________GPD
Temperature- Summer: ________Fº
Temperature- Winter: _________Fº

Comments/Notes: See comments
above._________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________

Injection Facility Insp. Report (Rev. Sept 2009) Page 4 of 4 Pages