Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9692 -94- 8912.000 Parcel #: 139692- 0014 -45 Application #: 11 -5 -26674 Subdivision: Lot #: 4a
Applicant Name: Randall Scott Byrd
Address: 1275 Peach Farm Rd. Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be 100 ft from any part of septic system
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 ere
Authorized State Agent C !ff Date JS 1�'_ ( /Z.
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)
From To
From To
From To
Ca sing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks:
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
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:11-5 -26674 Applicant Name: Randall Scott Byrd Subdivision: Lot #: 4a
Well Construction Sketch
Septic
Well Repair
Area Area
100 ft.
Home
30 ft —
Ingress /Egr Septic Drain field
ess Area
Easement
Well Completion Sketch