Signed Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 13 -5 -30642
Applicant Name: Kenneth Cummings
Address: 1214 Mt. Pisgah Church Rd.
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction system
Permit Conditions: Well to be drilled in Well Area
Subdivision: Lot #:
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 _
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
Date: 9/27/2013 Application #:13 -5 -30642
WELL CERTIFICATE OF COMPLETION
Well Contractor: Jackson Well Co.
Applicant Name: Kenneth Cummings
Address: 7893 Cool Springs Rd. Broadway, NC 27505
Directions to Site: 421 toward Sanford to left on Mt Pisgah Church Rd.l mile on right
Use of Well: sfd Date Drilled: 4 -11 -13 Total Depth: 180 ft Replacement Well? ❑ Yes ® No
Static Water Level: 40 ft Top of Casing is 12 in. above surface. Yield: 100 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth) Casin1l
From 140 ft To 142 ft From 0 To 125 ft
From To Diameter: 6.8 Material: pvc Thickness: sr 21
From To From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
Inspector: On Hold Date: Release Date: 9/30/13
Remarks:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: yes Vent Stack: yes
Well ID Tag: yes Pump ID Tag: des Sampling Tap: yeses
Sample Taken? ❑ Yes ® No Well Head properly sealed: yes
Remarks:
Grout
From 0 To 20 ft
Material: sand cement Method: pour
From To
Material: Method: _
From To
Material: Method:
Backflow Preventer:
� 120-7
Authorized State Agent u --�=�. Date
See Attachment for completion sketch
Application #:13 -5 -30642 Applicant Name: Kenneth Cummings Subdivision: Lot #:
Well Construction Sketch
Well Area
Septic tank 100 ft. +
90 ft.
Septic
Drain
field & House
Repair
Area
Well Completion Sketch
Septic tank 100 ft. +
Nell
0 v
Septic
Drain
field & House
Repair
Area