Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0612 -18- 2512.00 Parcel #: 13 0602 0130 Application #: 12 -5 -28377 Subdivision:
Applicant Name: Kenneth King
Address: 912 Womack Rd. Broadway, NC 27505
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in well area
Lot #:
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 #:12 -5 -28337
Well Contractor: Jackson Well Co.
Applicant Name: Kenneth King
Address: 912 Womack Rd. Broadway, NC 27505
Directions to Site: 421 towards Broadway turn right on Coolsprings Rd. turn right on Womack
Use of Well: sfd Date Drilled: 2 -29 -2012 Total Depth: 240 ft Replacement Well? ® Yes ❑ No
Static Water Level: 75 ft Top of Casing is 12 in. above surface. Yield: 40 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth) Casin Grout
From 218 To 220 From 0 To 95 ft From 0 To 20 ft
From To Diameter: 6.18 Material: pvc Thickness: sr21 Material: sand cement Method: pour
From To From To From To
Diameter: Material: Thickness: Material: Method: _
From To From To
Diameter: Material: Thickness: Material: Method:
Inspector: bm On Hold Date: Release Date: 4/26/2012
Remarks:
Well Head Information
Casing Height: 12 in (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 Date
22-C /?-c/2-
See Attachment for comp etion sketch
Application #:12 -5 -28377 Applicant Name: Kenneth King Subdivision: Lot #:
Well Construction Sketch
Septic
system
Home
50 ft.
50 ft.
drive WELL
WELL AREA
AREA
Womack Rd.
Well Completion Sketch
Septic
system
Home
50 ft.
drive
Well
Womack Rd.