Signed Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN Parcel Application 08-5-19917 Subdivision: Lot
Applicant Name: Stacey McCracken
Address: 221 Attie Lee Lane Sandord N.C. 27330
Type of Facility Served by Well: SFD
Sewage System: Pump to Conventional
Permit Conditions: Well must be 100 ft from septic tanks and system and 25 ft from any building foundation
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 rev cation
Authorized State Agent Date / 4 C l z~6
Grouting Inspection W tnessed 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:
Static Water Level:
Top of Casing is
Disinfection: Type
Amount
Water Zone (depth)
Casing
From To
From To
From To
Diameter:
From To
From To
Diameter:
From To
Diameter:
Inspector:
On Hold Date:
Remarks
Total Depth: Replacement Well? ❑ Yes ❑ No
in. above surface. Yield:
gpm at ft.
Grout
From 0 To
Material: Thickness:
Material: Method:
From To
Material: Thickness:
Material: Method:
From To
Material: Thickness:
Material: Method:
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
Date
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:08-5-19917 Applicant Name: Stacey McCracken Subdivision: Lot
Well Construction Sketch
E H
P O
T U
I S
C E
S A
Y R
S E
T A L1-~ Septic
E Tank
M
100 ft
Well
Area
Well Completion Sketch