Well AbandonmentHARNETT COUNTY DEPARMENT OF PUBLIC HEALTH
Well Abandonment Permit
Permit Number: Application Number: ��'� LPA$pplicant Name:
nt%e�,,a„JaQ/�� .etre
Address: P (bZX -7Z'7 Z)U1i10 Nr,. S0333S'
Type of Well: Total Dept: :5Z> Diameter: 2.4 Grouted: -- Static Water Level: i7
Directions to Site:
Agent of the Stj�Date. 3-3e) -/7
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. 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.
o� 313 0 ► f'7
Owners or Owners Legal Representative Signature Required Date
I-] - S qOM
Harnett County Department of Public Health
Well Abandonment Permit Application
APPLICANT INFORMAJION
c,Ul B D fps UL 410) g 2-`i31s
Applicant/Owner Phone Number
P O Sox 71s1 D k N %J NG 21304 -
Street Address, City, State, Zip Cade (40. 3 2,143
PROPERTY INFORMATION
Street Addrass 242. LM FM R:t> Srbdivisiotatlmt # i ,
Parcel 0 0(/53 0097 _ PiNx 6(p5 -3-4A-0131.000
Directions fo an Slee
OS
Btie� udeacripl hof t l dw (� front l�� behind out budding, from yard, etc.)
•Pkat beclude a S e Pian of your property showing the lorstion of the well. Ir o se
well Is uaele►greasod, N mast be uncovered prior to the department's she vkle.
Pkat Complete the Foilowlne Informstletn:
Date Well Was Cgr�torted 1 q'13 Grouted: Yes C No G
Above Ground 6/ or Below Ground C Total Depth of Well
Well Type: Drilled C Bored r: Handdug L- Diameter inches
1 have therwahly read and completed thlt Application sod certify that the Isformtha provided
hertk L Vee, complete and correct to the bed of my knowledge and b give In hood faith.
Representatives of the Hanett County Health Oepanment and State Officials see pored r4ht of
entry to modest nermery Inspection to determine complitoce with applicable rater.
I uWerseand near I arts aakly mVontihk for tits proper idenlifirotiun and labrling of all pmoperfv liner,
underemund wiVity tinea, nerd muking the site err &table 4-n that a wdl enn hr prupr4 mminwied
nerording to Or permit. �.�,(�
so -a, 6L 21
Property Owner's of Owner's Legal Representative Signume Required Dite
It you have any quest inn, please eoniect Environmental Health Division at 010493-7517