Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0524 -17 -1258 Parcel #: 010524007401 Application #: 11 -5 -26736 Subdivision: Lot #:
Applicant Name: Andrew S. Ruhland
Address: 120 Mockingbird Ln. Spring Lake, NC 28390
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be 100 ft. away form septic system and 25 ft. from building foundation
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 .s c,, ���f� Date Ls !/
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)
Casina
From
To
From
From
To
Diameter:
From
To
From
Diameter:
From
Diameter:
Inspector: On Hold Date:
Remarks:
Grout
To From 0 To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
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
Date
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:11 -5 -26736 Applicant Name: Andrew S. Ruhland Subdivision: Lot #:
Well Construction Sketch
WjArea __? f t_,
Home
1 ft.
Septic
System
Drive Way
Well Completion Sketch