Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0505 -63- 2230.000 Parcel #: 01 0505 0009 Application #: 11 -5 -26842
Applicant Name: Mitzi D. Allison
Address: 513 Maxine St. Fayetteville, NC 28303
Type of Facility Served by Well: Muitifamily
Sewage System: conventional
Permit Conditions: Well MUST be at least 100 ft from any septic system
Subdivision: Country Acres MHP 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 d Date 1 ; Z- ° 1 /
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
Inspector:
Remarks
Casin
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
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:11 -5 -26842 Applicant Name: Mitzi D. Allison Subdivision: Country Acres MHP Lot #:
Well Construction Sketch
R MH —�
A
Y
Septic
R Drain
0 Sonny Dee Drive
fields
A
D
100" ft.
MH Septic
--i Drain — — --► rArea
field
Well Completion Sketch