Signed Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0642 -25- 2185.000 Parcel #: 08 0645 0101 25 Application #: 11 -5 -25957 Subdivision: Lot #:
Applicant Name: Peter Ormond
Address: Christian Light Rd. Fuquay Varina, NC 27526
Type of Facility Served by Well: SFD
Sewage System: large diameter pipe
Permit Conditions: Well to be drilled in well area
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
c Dat e vZ 51 X"l-I /
Authorized State Agen " C ,�._ �,>�:...., �C
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:
Static Water Level: Top of Casing is in. above surface
Disinfection: Type Amount
Water Zone (depth)
From To
From To
From To
Inspector:
Remarks
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: _ 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
Replacement Well? ❑ Yes ❑ No
Yield: gpm at ft.
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Date
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:l 1 -5 -25957 Applicant Name: Peter Ormond Subdivision: Lot #:
Well Construction Sketch
Well Area
Septic
Tan 25
100
House
d
r
i
V
e
Septic Drain Field &
Repair Area
Well Completion Sketch