Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0536 -88- 8788.000 Parcel #: 010545 0062 Application #: 11 -5 -26125 Subdivision:
Applicant Name: Schumacher Homes (Kelly Hayes)
Address: 6815 Fayetteville Rd, Ste. 204, Durham NC 27713
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be 100 min from any part of septic system
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 Agent
Date
Grouting Inspection Witnessed Date _
❑ Grouting self - certified by driller GW -1 provided? ® Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 6/1/2011 Application #:11 -5 -26125
Well Contractor: NW Poole Well & Pump
Applicant Name: Schumacher Homes (Kelly Haves)
Address: 6815 Fayetteville Rd. Ste. 204 Durham NC 27713
Directions to Site: 210 south to Mike Williams Ln turn left
Use of Well: sfd Date Drilled: 5/23/2011 Total Depth: 307 ft Replacement Well? ❑ Yes ® No
Static Water Level: 25 ft Top of Casing is 12 in. above surface. Yield: 10 gpm at ft.
Disinfection: Type Amount
Water Zone (depth) Casing Grout
From To 294 From +1 To 139 From 0 To 20
From To Diameter: 6.25 Material: galv Thickness: .188 Material: cement Method: pQur
From To From To From To
Diameter: Material: Thickness: Material: Method:
From To From To
Diameter: Material: Thickness: Material: Method:
Inspector: bra On Hold Date: Release Date: 6/1/2011
Remarks
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: yes Vent Stack: yes
Well ID Tag: y_esPump ID Tag: }_es Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes ® No Well Head properly sealed: yes
Remarks:
Authorized State Agent
��J Date
See Attachment for completion sketch
Application #:11 -5 -26125 Applicant Name: Schumacher Homes (Kelly Hayes) Subdivision: Lot #:
Well Construction Sketch
Septic
Drain field
Area Septic
ank
ouse
100 ft
rWellea
Well Completion Sketch
Septic
Drain field
Area Septic
ank
ouse
100 ft