Well Abandonment Permit (2 Wells)AARNETT COUNTY DEPARMENT OF PUBLIC
Well Abandonment Permit
Permit Number: Application Number: Applicant Name: NWHVF Department
Address: 6015 Christian Light Rd. Fuquay Varina NC 27526
Type of Well: Hand Dug Total Dept: 23 ft. Diameter: 42 in. Grouted: no Static Water Level: 21 ft.
Directions to Site: 401 to Christian Light Rd. turn left on Cokesbury Rd go to intersection of Cokebur.and
River Rd-
Agent of the State r wb;_ ,c f Date: d ZG/
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 tile 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. 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; 5. 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; 6. 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. A record of the abandoment must be submitted within 30 days of
abandonment.
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.
House
Hand Dug--�
Well
Cokesbury Rd.
D
R
I
E
Op Bored Well
Property Owner's or Owners Legal Representati ature Required Date
Harnett County Department of Public Health
Well Abandonment Permit Application
APPLICANT INFORMATION
019 )—E5,?- S3 9 f
Applicant/Own Phone Number
X015 acs4f,J Wr M : �vcil
Street Address, City, State, kip Code
PROPERTY INFORMATION
FMQ\ 64ce1 j\a- 2752
Street Address 31ap Cokt gtr�_ Subdivision/Lot #
Parcel #
PIN #
Directions to the Site
US N ILo Cie m /
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rief description of the well location (ex. front yard, behind out building, front yar , eta
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19 o oveift
*Please include a Site Plan of youY property showing the location of the well. If the
well is underground, it must be uncovered prior to the department's site visit.
Please Complete the Following Information:
Date Well Was Constructed U o ek� 0U v Grouted: Yes C No G -7
Above Ground C or Below Gro p e V il�?lb,o
nd G Total Depth of Well f>�
Well Type: Drilled C Bored and dug EVZ Diameter AD inch— es
I 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 t am solely responsible for the proper identification and labeling gftill properly lines,
underground utility lines, and making the site accessible so that a swill can be properly constructed
according to the perutit"
Property Owner's of Owner's
Signature Required
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If you have any uestions please contact Environmental Ilea Ith Division at 910- 893 -7547