New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0507-80-6681.000 Parcel Application 11-5-27053 Subdivision: AC Turlington Lot
Applicant Name: Otis Butler
Address: 1912 Nursery Rd. Lillinaton, NC 27546
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be at least 100 feet away from any part of septic system
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 t.- ACV- D '7/0- u t/
b
Grouting Inspection Witnessed Date
❑ Grouting self-certified by driller GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application Well Contractor:
Applicant Name:
Address:
Directions to Site:
Use of Well:
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Static Water Level:
Top of Casing is
in. above
surface. Yield:
gpm at ft.
Disinfection: Type
Amount
Water Zone (depth)
Casing
Grout
From To
From To
From 0 To
From To
Diameter:
Material:
Thickness:
Material:
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:
Remarks:
Well Head Information
Casing Height: (above finished grade) Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent Date
See Attachment for completion sketch
Application #:11-527053 Applicant Name: Otis Butler Subdivision: AC Turlington Lot
Well Construction Sketch
Septic
Tan
Septic
Drain Field
Home
& Repair
100 feet
Area
WELL
AREA
Path
Well Completion Sketch