Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9553 -86- 5214.000 Parcel #: 09 9553 0017 Application #: 12 -5 -28489 Subdivision: Lot #: 2A
Applicant Name: James A. Myers
Address: 6492 Phillip i Church Rd. Raeford, NC 28376
Type of Facility Served by Well: SFD
Sewage System: 25 % Reduction System
Permit Conditions: Well to be 100 ft from septic system
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 — ��. �6:_ i �(f Date - !/ 1z 2--
Grouting Inspection Witnessed Date
❑ Grouting self - certified by driller GW -1 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)
From To
From To
From To
Casin
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks:
On Hold Date: Release Date:
Well Head Information
Casing Height: (above finished grade) Access Port:
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks
Authorized State Agent
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:12 -5 -28489 Applicant Name: James A. Myers Subdivision: Lot #: 2A
Well Construction Sketch
Septic
11 0(ft_ Tank
Garage
(EHome
100 ft.
D
R
I
V
E
Well Completion Sketch