Signed Well Completion 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
Date
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
Date: 5/28/2015 Application #:15-5-35661R
WELL CERTIFICATE OF COMPLETION
Well Contractor: Jackson Well Co.
Applicant Name: James Stahl
Address: 808 Mike Williams Rd
Directions to Site: 210 South left on Mike Williams Rd
Use of Well: sfd Date Drilled: 5/15/2015 Total Depth: 320 ft Replacement Well? ❑ Yes ® No
Static Water Level: 100 ft Top of Casing is 12 in. above surface. Yield: 10 gpm at ft.
Disinfection: Type lith Amount 16 oz
Water Zone (depth) Casing Grout
From 242 To 244 From 0 To 160 ft From 0 To 20 ft
From To Diameter: 6.185 Material: pvc Thickness: sr 21 Material: sand cement 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: 5/28/2015
Remarks:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: }_es Vent Stack: des
Well ID Tag: �esPump ID Tag: des Sampling Tap: yeses Backflow Preventer: des
Sample Taken? ❑ Yes ® No Well Head properly sealed: yes
Remarks:
Authorized State Agen �w�4L, Date 2 10,4x—
See
Attachment for completion sketch
Application #:15-5-35661R Applicant Name: James Stahl Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch
Septic
Tank Home
Septic drain field and repair
area
100 ft.
Well Area
Mike Williams Ln.
Septic
Tank Home
Septic drain field and repair
area
100 ft.
Well
Mike Williams Ln.