Signed Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-35661R
Applicant Name: James Stahl
Address: 875 Mike Williams 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 z I�Z2_
Grouting Inspection Witnessed 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
From
To
From _
From
To
Diameter:
From
To
From _
Diameter:
From _
Diameter:
Inspector: On Hold Date:
Remarks:
Grout
To From 0 To
_ Material: Thickness: Material: Method:
To From To
_ Material: Thickness: Material: Method:
To 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.
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #:15-5-35661R
Well Construction Sketch
Well Completion Sketch
Applicant Name: James Stahl Subdivision: Lot #:
Septic
Tank Home
100 ft.
Well Area
Septic drain field and repair
area
Mike Williams Ln.