New Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 11 -5 -25990 Subdivision: Lot #:
Applicant Name: Norman Levon Cameron
Address: P.O. Box 336 Broadway, NC 27505
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled above natural drain
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
See attachment for construction sketch
GW -1 provided?
Date _
Yes ❑ No
WELL CERTIFICATE OF COMPLETION
Date: 3/18/2011 Application #:11-5-25990
Well Contractor: Jackson Well Company
Applicant Name: Norman Levon Cameron
Address: P.O. Box 336 Broadway, NC 27505
Directions to Site: old 421 past Boone Trail School to Sloan Rd property on right
Use of Well: sfd Date Drilled: 3 -4 -2011 Total Depth: 200 ft Replacement Well? ❑ Yes ❑ No
Static Water Level: 45ft Top of Casing is 12 in. above surface. Yield: 25 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth) Casing
From 194 To 195 From 0 To 80
From To Diameter: 6in Material: pvc Thickness: sr21
From To From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
Inspector: bin On Hold Date: Release Date: 3/18/2011
Remarks:
Grout
From 0 To 20
Material: sand cement Method: o� urine.
From To
_ Material: Method:
From To
Material: Method:
Well Head Information
Casing Height: 12in (above finished grade) Access Port: }_es Vent Stack: des
Well ID Tag: yesPump ID Tag: y�js Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Date
Authorized State Agent f �/l. / Dat . k
See Attachment for completion sketch
Application #:11 -5 -25990
Well Construction Sketch
Applicant Name: Norman Cameron Subdivision: Lot #:
Well Area
S
1
0
a
n
N
Existing
Barn
Natural Drain
Septic System Area &
Home Repair
Old US 421
Well Completion Sketch
Natural Drain
S
1
0
a
n
Existing
Barn
Well
+100 ft
Septic System Area &
Home Repair
Old US 421