Well Abandonment PermitHARNETT COUNTY DEPARMENT OF PUBLIC HEALTH
Well Abandonment Permit
0ermit Number: Application Number: 09-5-2271 OR Applicant Name: Shirley Johnson
Address: 32 Old Mail Lane Coats NC 27521
Type of Well: driven Total Dept: ? Diameter: 1.25 in Grouted: no Static Water Level: ?
Directions to Site: 27 east toward Benson turn left on Festus Rd about 3/4 mile on right
Agent of the States f Date:
Abandonment Procedure: Abandonment Procedure: 1. Remove all plumbing or piping into the well, along
with any obstructions inside the well; 2.Remove as much of the well the casing a possible, but no les than to a
depth of three feet below land surface; 3. remove all soil or other subsurface material present down to the top of
the remaining well casing, and extending to a width of at least 12 inches outside of the well casing on all sides;
4. Using 5 oz. of hypochlorite solution (such as HTH), disinfect the well in accordance with 15A NCAC 2C
.0111 of this Subchapter. Do not use a common commercial household liquid bleach, as this is too weak a
solution to ensure proper disinfection; 5. Fill the well up to the top of the remaining casing with cement grout,
concrete grout, bentonite grout, dry clay, or material excavated during drilling of the well and then compacted
in place; 6. Pour a one foot thick concrete grout or cement grout plug that fills the entire excavated area about
the top of the casing, including the area extending on all sided of the casing out to a width of at least 12 inches
on all sides; 7. Complete the abandonment process by filling the remainder of the well above the concrete or
cement plug with additional concrete grout, cement grout, or soil.
Note: Contact Harnett County Environmental Health for appointment prior to beginning of well abandonment
procedure.
Well must be abandoned by a Certified North Carolina well driller/contractor.
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Harnett County Department of Public Health
Well Abandonment Permit Application
APPLICANT INFORMATION
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PROPERTY INFORMATION
Street Address M Y~~--t L&-r~ Subdivision/Lot #
7Parcel # J ~
PIN #
Directions to the Site
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ttn (ea. front yard, behind out building, front yard, etc.)
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*Please include a Site Plan of your property showing the location of the well. If the
well is underground, it must be uncovered prior to the department's site visit.
Please Comolete the Following Information:
Aate Well Was Constructed,,, ,
Above Ground :1 or Below (3round 7
Well Type: Drilled Bored J Hand dugs
Grouted: Yes D No :3
Total Depth of Well
Diameter inches
1 have thoroughly read and completed this Application and certify that the information provided
herein is true, complete and correct to the best of my knowledge and is give in good faith.
Representatives of the Harnett County Health Department and State Officials are granted right of
entry to conduct necessary inspections to determine compliance with applicable rules.
I understand that I am solely responsible for the proper identification and labeling of all property lines,
underground utility lines, and making the site accessible so that a will can be properly constructed
according to the pyrmit.
Property Owner's of
q-y-CC
Required
If you have any questions please contact Environmental Health Division at 910-893-7547