Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0546 -74- 8784.000 Parcel #: Application #: 12- 5- 29057R Subdivision: Lot #: 12
Applicant Name: Clayton Homes
Address: 3912 Fayetteville Road Raleigh, NC 27603
Type of Facility Served by Well: SFD
Sewage System: Pump to 25% Reduction System
Permit Conditions: Well to be drilled in Well Area
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 ,� �,--.� ll -:- , Date l 7 S 2 l �
0
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
Casing
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 Agent
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:12- 5- 29057R Applicant Name: Clayton Homes Subdivision: Lot #: 12
Well Construction Sketch
McLean Chapel Church Road
Repair Septic
Area Drain Field
Home E
100 ft. 0� Septic tank
100 ft.
WELL
AREA Garage
25 ft.
Well Completion Sketch