Well Completion 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
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: 8/1/2012 Application #:12- 5- 29057R Well Contractor: Van Elliott
Applicant Name: Clayton Homes
Address: 3400 Mclean Chapel Church Rd. Bunnlevel, NC 28323
Directions to Site: 410 to Bunnlevel turn right on McLean Chapel Church Rd
Use of Well: sfd Date Drilled: 7/24/2012 Total Depth: 320 ft Replacement Well? ❑ Yes ® No
Static Water Level: 50 ft. Top of Casing is 12 in. above surface. Yield: 20 gpm at ft.
Disinfection: Type Amount
Water Zone (depth) Casing
From 300 ft. To From 1 To 95 ft
From To Diameter: 6in Material: pvc Thickness:
From To From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
Inspector: bin On Hold Date: Release Date: 8/1/2012
Remarks
Grout
From 0 To 20
Material: Portland cement Method: 'Lour
From To
Material: Method:
From To
Material: Method:
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 FI 2GlZ
See Attachment for completion sketch
Application #:12- 5- 29057R
Well Construction Sketch
Applicant Name: Clayton Homes Subdivision: Lot #: 12
McLean Chapel Church Road
[ Repair Septic
Area Drain Field
E Home
100 ft. 0`',_ Septic tank
100 ft.
WELL 7
AREA Garage
25 ft.
Well Completion Sketch
McLean Chapel Church Road
Repair Septic
Area Drain Field
Home E
100 ft. E:l Septic tank
25 ft.
--- /®
100 ft.
Garage