Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 13 -5 -30396 Subdivision: Lot #:
Applicant Name: La Rene S. Branch
Address: 160 Peaceful Ln. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: 25 % Reduction System
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
Grouting Inspection Witnessed
❑ Grouting self - certified by driller GW -1 provided?
See attachment for construction sketch
Date
Date _
Yes ❑ No
WELL CERTIFICATE OF COMPLETION
Date: Application #:13 -5 -30396 Well Contractor: Jackson Well Co.
Applicant Name: La Rene Branch
Address: 160 Peaceful In
Directions to Site: 210 S. to Bethal Baptist Rd. turn left to Peaceful turn left
Use of Well: sfd Date Drilled: 8/1/13 Total Depth: 180 ft Replacement Well? ❑ Yes ® No
Static Water Level: 40 ft Top of Casing is 12 in. above surface. Yield: 40 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth) Casing
From 146 ft To 150 ft From 0 To 96 ft
From To Diameter: 6 in Material: pvc Thickness: sr21
From To From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
Inspector: bm On Hold Date: Release Date: 9/24/13
Remarks:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: Yes Vent Stack: yes
Well ID Tag: yes Pump ID Tag: yes Sampling Tap: yes
Sample Taken? [:]Yes ® No Well Head properly sealed: yes
Grout
From 0 To 20 ft
Material: sand/cement Method: pour
From To
Material: Method: _
From To
Material: Method:
Backflow Preventer:
Remarks:
Authorized State Agen�� -�o-:. e� Date /ZZ 2a /7
See Attachment for completion sketch
Application #:13 -5 -30396
Well Construction Sketch
Applicant Name: La Rene S. Branch Subdivision: Lot #:
100 ft.
Well Area
Well Completion Sketch
Septic
Drain field
Area
Septic
- -- Tank
New Home
Garage
Septic
Drain field
Area
P
A Septic
T Tank
H
New Home
100 ft.
Garage
Well