Well AbandonmentHARNETT COUNTY DEPARMENT OF PUBLIC HEALTH
Well Abandonment Permit
Permit Number: 29484 Application Number: 17-5-42423
Applicant Name: Wynn Construction, Inc
Address: 7201 Creedmoor Road, Suite 147 Raleigh, NC 27613
Type of Well: Hand Dug Total Depth: l Oft Diameter: 48in Grouted: No Static Water Level: None
Directions to Site: Hwy 401 N. toward Fuquay-Varina. Left on Chalybeate Rd. Left onto Avery Pond Drive.
Location on right Lot 67 is 4' lot on right.
Agent of the St —Date-.: 16— 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. 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 abandonment must be submitted within 30 days of
abandonment.
Note: Contact Harnett County Environmental Health for appointment prior to beginning of well abandonment
procedure.
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Property Oxfder's or Owners Legal Representative Signature
Harnett County Department of Public Health
Well Abandonment Permit Application
APPLIC.A I INFORMATION yS 3q�a CMob'lc�
119-1
,^ - Lo.,, Y/y ► sa 8 Icy
A etiowiw Phone Nnlnher
Street Address, City. State, Zip Code
PROPE/RTY/INFORMATION �+
Street Address_ j�y Z"� A,. SrbdlvisimuLot M ✓ems 4,7c/ Z.:, f 67
Parcel tM
PIN 11 eL-52_y%-3135.x0_,
Directions to the Site
Brieldercrt n of the +sell locations lei. fro% yard, behind out huddling, front yard ete.l
eG% <r..- ('a. ns.- „,o
sPletae include a Site Pin of your property showing the location of the well, if the
well Is underground. It must be uncovered prior to the department's slit visit.
Please Complete the Folio" Jae Information:
Date Well Was Consnuctcd E)K,J /— ;) Grouted: 1 es t No -�
Aboyc Ground L of Below Ground F�- Total Depth of Well /0
Well Type: Drilled bored �ilaud dug Diameter irtchns
I hast ehnraaghry r. d and c.mid,n d thio AWirellnn and eeerlfy 111,1 the isfam alim pra.idral
herela Is true, complete and eorrea to thr best M m) t nswi a e aN Ice gt.e in goad faith.
Repmentali," of the Haroett Count) Health (eparru.ent aN Mine Officials an gated right of
ever)to coadvel arcawary inspMionx to detrrndne rVnnpaaac, with applicable rules.
1 aaderoawd rhw lax wleh i
vxd.ryerwaad wrfity linrx, aced
fart axd WMiiae aJafl pnre+er lwrr.
xif! can N�~rHy exnnnlrhd
If Wu hast ray Qaeanan pre isr ttmtwt Eanvournm al Health Hmooa at o laao 3 : s♦;
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