Well Completion 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:
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
Lot #: 4c
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: 6/11/2014 Application #:11 -5 -27125 Well Contractor: Jackson Well
Applicant Name: John C. Pavlikianidio
Address: 386 Taylor Rd
Directions to Site: 27 west to Nursery Rd to Taylor Rd
Use of Well: sfd Date Drilled: 4/25/14 Total Depth: 180 ft Replacement Well? ❑ Yes ® No
Static Water Level: 31 ft Top of Casing is 12 in. above surface. Yield: 30 gpm at ft.
Disinfection: Type hth Amount 12 oz
Water Zone (depth) Casing Grout
From 152 To 154 From 0 To 104 ft From 0 To
From To Diameter: 6.8 Material: pvc Thickness: sr21 Material: concret Method: pour
From To From To From To
Diameter: Material: Thickness: Material: Method:
From To From To
Diameter: Material: Thickness: Material: Method:
Inspector: bm On Hold Date: Release Date: 6/11/14
Remarks:
Well Head Information
Casing Height: 1 ft (above finished grade) Access Port: des Vent Stack: }_es
Well ID Tag: yes Pump ID Tag: yes Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes ® No Well Head properly sealed: }_es
Remarks:
c
Authorized State Agent — .,,� C' Date / / °1
See Attachment for completion sketch
Application #:11 -5 -27125
Well Construction Sketch
Well Completion Sketch
Applicant Name: John C. Pavlikianidio Subdivision: Lot #: 4c
Septic System & Repair Area
D f-- ------ Septic tank
Home
; 0+
Well Area
25 0
Septic System & Repair Area
D
R
I
V
E
D *---- Septic tank
Home
50+
D
R
Well
0 I
V
E
25 ft.1