Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0505 -29- 5203.000 Parcel #: 010505 0025 05 Application #: 11 -5 -27125 Subdivision: Lot #: 4c
Applicant Name: John C. Pavlikianidio
Address: 386 Taylor Rd. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction w,' pump
Permit Conditions: well to be drilled in Well Area
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
c
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)
From To _
From To _
From To
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks:
On Hold Date: Release Date:
Well Head Information
Casing Height: (above finished grade) Access Port:
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:11 -5 -27125 Applicant Name: John C. Pavlikianidio Subdivision: Lot #: 4c
Well Construction Sketch
Septic System & Repair Area
0 4--' Septic tank
Home
50+ t.
D
R
I
Well Area V
E
25 ft.1
Well Completion Sketch