Well AbandonmentARNETT COUNTY DEPARMENT OF PUBLIC HEALTH
Well Abandonment Permit
Permit Number: Application Number: 11-5-27825 Applicant Name: James W Matthews
Address: 4375 US 401N F.V. N.C. 27526
Type of Well: Bored Total Dept: 26 Diameter: 24 Grouted: ? Static Water Level: 24
Directions to Site: Hwy 401
Agent of the Stat Date:
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.
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Owner's or Owners Legal Representative Signature Required Date
Harnett County Department of Public Health
Well Abandonment Permit Application
APPLICANT INFORMATION
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qAplicant]Owner j Phone Number
Street Address, City, State, Zip Code
PROPERTY INFORMATION
Street Address YV Suaivision/Lot #
Parcel # bCDS ! Do t k? PIN #jo &S` O~2O
Directions to the Site
Brief description of the well location (ex. front yard, behind out building, front yard, etc.)
*Please include a Site Plan of your property showing the location of the well. If the
well is underground, it must be uncovered prior to the department's site visit.
Please Complete the Following Information:
Date Well Was Constructed ? 1156 s e
Grouted: Yes G No Ct;
Above Ground C or Below Ground L4---~ Total Depth of Well_ ,l'
Well Type: Drilled G Bored 1-; Hand dug P''Diameter inches
I have thoroughly read and completed this Application and certify that the information provided
herein is true, complete and correct to the best of my knowledge and is give in good faith.
Representatives of the Harnett County Health Department and State Officials are granted right of
entry to conduct necessary inspections to determine compliance with applicable rules.
I understand that I an: solely responsible for the proper identification and labeling Qf all property lines,
underground utility lines, and making the site accessible so that a ivill can be properly constructed
according to the permit.
Owner's of Owner's Legal Representative Signature Required
Date
If you have any questions please contact Environmental IIealth Division at 910-893-7547 l [
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Harnett County Zoning Overlay
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Owner Information
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NAME MATTHEWS
ADDRESS 4431 USS 4014
CITYST ' FUQUAY VAF
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