Well Completion 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
Applicant Name: Joseph Phillips
Address: 1964 Ray Rd. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Well to be 100 ft. from septic system
Lot #: 4
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
Date
Grouting Inspection Witnessed Date _
® Grouting self - certified by driller GW -1 provided? ® Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 4/26/2012 Application #:10- 5- 25584R
Well Contractor: Jackson Well Co.
Applicant Name: Joseph Phillips
Address: 1964 Ray Rd. Spring Lake, NC 28390
Directions to Site: 210 south to Ray Rd. turn left on Overhills Rd. turn right on Taylor
Use of Well: sfd Date Drilled: 4 -12 -12 Total Depth: 260 ft Replacement Well? ❑ Yes ® No
Static Water Level: 50 ft Top of Casing is 12 in. above surface. Yield: 30 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth)
From 240 To 294
From To
From To
Inspector: bm
Remarks:
Casing
From 0 To 140 ft
Diameter: 6.18 Material
From To
pvc Thickness: sr 21
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
On Hold Date: Release Date: 4/26/12
Grout
From 0 To 20
Material: sand /cement Method: pour
From To
Material: Method:
From To
Material: Method:
Well Head Information
Casing Height: 12in (above finished grade) Access Port: yes Vent Stack: yes
Well ID Tag: yesPump ID Tag: yes Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes ® No Well Head properly sealed: yes
Remarks:
Authorized State Agent �'G-- /t `� Date
See Attachment for completion sketch
Application #:10- 5- 25584R
Well Construction Sketch
Applicant Name: Joseph Phillips Subdivision: Tam Lot #: 4
Well Area
Home
I
100 ft.
Septic and
Pump tanks
drive
Septic Drain field
Well Completion Sketch
Well O
Home
i
100 ft.
Septic and
Pump tanks
drive
Septic Drain field