Well AbandonmentHARNETT COUNTY DEPARMENT OF PUBLIC HEALTH
Well Abandonment Permit
Permit Number: 26542Application Number: 11-5-27673 Applicant Name: Ken Dawson Homes
Address: 120 Edmondson DR Willow Springs N.C. 27592
Type of Well: Bored Total Dept: 12 Diameter: 30 Grouted: NO Static Water Level: NONE
Directions to Site: SR 1707 Neighbers Rd
Agent of the St 2 /&Q"~- - Date: lo- Z,- At
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 the 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
procedure. !5 a,, % `t0
Well must be abandoned
to beginning of well abandonment
Property Owne Owners Legal Representative Signature Required Date
Oct, 27, 2011 10: 26AM No, 0997 P. 1
a From:ENVIRONMENTAL HEALTH 910 893 9371 10127/2011 10:16 #797 P.001/001
Harnett County Department of Public Health
Well Abandonment Permit Application
APPLICANT INFORMATION
Appiieant/Owner`/ Phone Number
Street Address, City, State, Zip Code
/n~ PROPERTY INFORMATION
Street Address S'/ CSBc/tlt°r J, Subdivision/Lot 9,41'a3l
Farces # WL5e''$' ,no-)3 30 PIN # 15'.a6-3`} -39 5, WO
Directions to the Site
*Please include a Site plan of your property showing the location of the well. If the
welt Is underground, It must be uncovered prior to the departments site visit.
Plegse Complete the Following Inforrtaation; l✓ p,-ecAl-e. & &kf O'"37 Date Well Was Constructed a /v~ Grouted: Yes C No E--"'
Above Ground C or Below Ground I Total Depth of Well
Well Type: Drilled G Bored r Hand dug el"' Diameter inches
I have thoroughly read and completed this Applleailon and certify that the information provided
herein Is true, complete and correct to the best of my knowledge and Is give In goon faith.
Representatives of the Harnett County Health Department and State Offleiah Are granted right of
entry to Conduct necessary Inspections to determine compliance with applicable rules.
I understand that t any solely responsible for Me pr'oper itknuificatfon and labeling of elll property lines.
underground ufillry lfnes king the site accessible in that o w ill can he properly constructed
according to the perpiff
Prop y w -fier's of Owner gal Representative Signature Required Date
if you have any questions please contact Environmentni Health Division at 910.8934547
Brief description of the well locAtion ,Jex;,front yqd, behl9d out building, front yard, etc.)