Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0682-92-9336.000 Parcel 040682-0224-01 Application 11-5-27533 Subdivision: Pointers Creek
Applicant Name: SHC Holdings Inc
Address: 466 Stancil Rd Angier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: 25% RED
Permit Conditions:
Lot 1
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,
Date
Grouting Inspection Witnessed Date _
E] Grouting self-certified by driller GW-1 provided? F-1 Yes F-1 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 Date See Attachment for completion sketch
Application #:11-5-27533
Well Construction Sketch
Applicant Name: SHC Holdings Inc Subdivision: Pointers Creek Lot 1
Well Completion Sketch