Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-35566
Applicant Name: Scott C. Brown
Address: 245 Cooper Store Rd. Sanford, NC 27322
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in Well Area
Subdivision: Weswood Lot #: 16
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: 7/6/2015 Application #:15-5-35566
WELL CERTIFICATE OF COMPLETION
Well Contractor: WW Maness & Sons
Applicant Name: Scott C. Brown
Address: 245 Cooper Store Rd
Directions to Site: 27 w to 24/27 to county line rd to mecsadies to outlaw
Use of Well: sfd Date Drilled: 4/20/15 Total Depth: 260 ft Replacement Well? ❑ Yes ® No
Static Water Level: 115 ft Top of Casing is 12 in. above surface. Yield: 10 gpm at ft.
Disinfection: Type lith Amount 16 oz.
Water Zone (depth) Casing
From 196 To From 0 To 178
From To Diameter: 6.25 in Material: pvc Thickness
From To From To
Diameter: Material: Thickne
From To
Diameter: Material: Thickne
Inspector: bm On Hold Date: Release Date: 7/6/2015
7/
Remarks:
Grout
From 0 To 20 ft
sdr 21 Material: sand cement Method: pour
From To
ss: Material: Method: _
From To
ss: Material: Method:
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: Yes Vent Stack: Yes
Well ID Tag: }_es Pump ID Tag: des Sampling Tap: des Backflow Preventer: des
Sample Taken? ❑ Yes ® No Well Head properly sealed: yes
Remarks: t X
Authorized State Age ` C'_ r Date / I/fes
See Attachment for completion sketch
Application #: 15-5-35566 Applicant Name: Scott C. Brown Subdivision: Weswood Lot #: 16
Well Construction Sketch
Well Completion Sketch
Existing
Septic
System
Existing
House
Foundation
100 ft.
Well Area
Outlaw Ln
Existing
Septic
System
Existing
House
Foundation
100 ft.
0
Well
Outlaw Ln