Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0504 -49 -7697 Parcel #: 010504 001102 Application #: 10- 5- 25584R Subdivision: Taylor Lot #: 4
Applicant Name: Joseph Phillips
Address: 1964 Ray Rd. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction Syste
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 ,%ee Date 7 12—(. 4 d/ Z
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
Inspector:
Remarks:
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
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
Date
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:10- 5- 25584R
Well Construction Sketch
Applicant Name: Joseph Phillips Subdivision: Tam Lot #: 4
Well Area
1
100 ft.
drive
Septic Drain field
Septic and
Pump tanks
Well Completion Sketch