Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN Parcel Application
Applicant Name:
Address:
Type of Facility Served by Well: SFD
Sewage System:
Permit Conditions:
Subdivision: Lot
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: 2-18-11 Application #:10-5-25573
Applicant Name: Donnie and Vickie Gainey
Address: 1768 Turlin toy n RD
Directions to Site:
Well Contractor: Roger Jackson
Use of Well: consurntion Date Drilled: 1-20-11 Total Depth: 340 Replacement Well? ❑ Yes ® No
Static Water Level: 120 Top of Casing is 12 in. above surface. Yield: 30 gpm at ft.
Disinfection: Type Amount
Water Zone (depth)
From To
From To
From To
Inspector: JEM
Remarks:
Casing
From 0 To 20
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To 20
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Well Head Information
Casing Height: 12" (above finished grade) Access Port: YES Vent Stack: YES
Well ID Tag: YES Pump ID Tag: Sampling Tap: YES Backflow Preventer: YES
Sample Taken? ❑ Yes ® No Well Head properly sealed: YES
Remarks:
Authorized State Age Z Date
See Attachment for completion sketch
Application j~ - Applicant Name: Subdivision: Lot
25573 /V)I 4~ V-rcQe
Well Construction Sketch
Well Completion Sketch