Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application # 15-5-35248
Applicant Name: Randy Nalls
Address: P.O. Box 488 Hope Mills ,NC 28348
Type of Facility Served by Well: SFD
Sewage System: 25 % reduction
Permit Conditions: Well to be drilled in Well Area
Subdivision: Lot #: 31A
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
Date: 6/4/2015 Application #:15-5-35248
Applicant Name: Rand
Address: 805 Loop Rd.
Directions to Site: 210 south to Loop Rd.
WELL CERTIFICATE OF COMPLETION
Well Contractor: Cape Fear Well & Pump
Use of Well: sfd Date Drilled: 6/4/2015 Total Depth: 265 ft Replacement Well? ❑ Yes ® No
Static Water Level: 43 ft Top of Casing is 12 in. above surface. Yield: 20 gpm at ft.
Disinfection: Type hth Amount 100 ppm
Water Zone (depth) Casing Grout
From 140 To 160 ft From 0 To 114 ft. From 0 To 20
From To Diameter: 4.5 in Material: pvc Thickness: sdrl7 Material: hole plug Method:
From To From To From To
Diameter: Material: Thickness: Material: Method:
From To From To
Diameter: Material: Thickness:- Material: Method:
Inspector: On Hold Date: Release Date: 7/8/2015
Remarks:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: }_es Vent Stack: yes
Well ID Tag: yesPump ID Tag: 5—es Sampling Tap: 3—es Backflow Preventer:
Sample Taken? ❑ Yes ® No Well Head properly sealed: Les
Remarks:
G
Authorized State Agen Date 7 2c fr
See Attachment for completion sketch
Application #:15-5-35248 Applicant Name: Randy Nalls Subdivision: Lot #: 31A
Well Construction Sketch
Well Completion Sketch
Area for
Initial and
Repair
D
Drain
R
House
Fields
I
V
E
W�11
100 ft.
Septic tank