Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: 03 9489 1044 01
Applicant Name: Fred A. Baker
Address: 17 Jefferson Ln. Cameron, NC 28326
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Well to be a minium of 85 ft from septic system and 100 from fence
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 rev cation
Authorized State Agent rt—"� Date / Y Zc/ 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:
Application #: 12 -5 -29077 Subdivision: Lot #:
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
Ca sing
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
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:12 -5 -29077
Well Construction Sketch
Applicant Name: Fred A. Baker Subdivision: Lot #:
MH
MH
Fence
100 ft.
1
Existing
Barn
Well Area
Drive way
M
Septic H
85 ft.
Tank
minimum
Septic Drain field & Repair Area
Well Completion Sketch