Signed Well PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN Parcel Application 08-5-19134 Subdivision: Joe B Tutor Lot 4
Applicant Name: Wesley Tutor
Address: Nickus Way, Fuquay Varina, NC 27526
Type of Facility Served by Well: SFD
Sewage System: EZ Flow
Permit Conditions: Well to be drilled in area stated on permit
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 10. Date ao
Grouting Inspection 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:
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 Agent Date
See Attachment for completion sketch
Application #:08-5-19134
Well Construction Sketch
Applicant Name: Wesley Tutor Subdivision: Joe B Tutor Lot 4
25 ft Shed
19.5 ft
WA 100ft~,-,
Septic Drain Field & Repair
Area
E R
L E Septic
L A Proposed Tank
House
Site
9ft
----------rt-----------------------.-----------------------------
25 ft Utility Easement
Well Completion Sketch