Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 11 -5 -27671
Applicant Name: Kim Young
Address: 128 Willette Lane Cameron, NC 28326
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in well area
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
Date
Grouting Inspection Witnessed Date _
❑ Grouting self - certified by driller GW -1 provided? F1 Yes F No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 1/12/2012 Application #:11 -5 -27671
Well Contractor: Cape Fear Well
Applicant Name: Kim Young
Address: 128 Willette Lane Cameron, NC 28326
Directions to Site: 27 west to 24/27 turn left on Hillman Grove and right on Willette
Use of Well: sfd Date Drilled: 11/14/2011 Total Depth: 270 ft Replacement Well? x Yes ❑ No
Static Water Level: 110 ft Top of Casing is 12 in. above surface. Yield: 50 gpm at 270 ft.
Disinfection: Type hth Amount 75pp
Water Zone (depth) Casin
From 210 To 270 From 0 To
From To Diameter: 4
From To From
Diameter: _
From
Diameter:
Grout
175 ft From 0 To 22 ft
.5 Material: pvc Thickness: sor 17 Material: cement Method: opur
To From To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
Inspector: bm On Hold Date: Release Date:
Remarks
Well Head Information
Casing Height: 1 ft (above finished grade) Access Port: }_es Vent Stack: yes
Well ID Tag: yes Pump ID Tag: yes Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes x No Well Head properly sealed: Yes
Remarks:
G
Authorized State Agent ,, a, , C Date
See Attachment for completion sketch
Application #:11 -5 -27671 Applicant Name: Kim Young Subdivision: Lot #:
Well Construction Sketch
Well Area
80 feet
Septic System
Home
Drive way
Existing
Well
Well Completion Sketch
OO Well
Septic
system
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