Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0545 -95- 7120.000 Parcel #: 12 0555 0011 13 Application #: 12 -5 -28302 Subdivision: Carroll
Applicant Name: Michael Waterstripe
Address: 193 Jerome Lane Linden, NC 28356
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be a minimum of 50 ft. from septic system
Lot #: 2
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
Casing
From 0 To 200 ft
Diameter: 6.18 Material
From To
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 #:12 -5 -28302
Well Contractor: Jackson Well Co.
Applicant Name: Michael Waterstripe
Address: 193 Jerome Lane Linden, NC 28356
Directions to Site: 401 to Bunnlevel turn right on Mclean Chaple Ch Rd. turn left on Wire turn right on Walker
Use of Well: sfd Date Drilled: 2 -29 -12 Total Depth: 260 ft Replacement Well? ® Yes ❑ No
Static Water Level: 22 ft Top of Casing is 12 in. above surface. Yield: 15 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth)
From 231 To 235 ft
From To _
From To
Inspector: bm
Remarks:
Date
pvc Thickness: sr20
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
On Hold Date: Release Date: 4/26/2012
Grout
From 0 To 20 ft
Material: sand cement Method: pgur
From To
Material: Method: _
From To
Material: Method:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: }_es Vent Stack: }_es
Well ID Tag: }_esPump ID Tag: des Sampling Tap: des Backflow Preventer:
Sample Taken? ® Yes ❑ No Well Head properly sealed: yes
Remarks:
G y/
Authorized State Date a ° . -Z
See Attachment for completion sketch
Application #:12 -5 -28302
Well Construction Sketch
Applicant Name: Michael Waterstripe Subdivision: Carroll Lot #: 2
Neighbor's
Drain lines
Property lin
100 ft
D
R
I
V
E
Home
Gate `—
Drain line
50 ft.
ost w/ flag ,
Well Completion Sketch
Neighbor's
Drain lines
Property lin
100 ft
Well
D
R
I
V
E
Gat
Home
Drain line
A-- 50 ft.
ost w/ flag