Signed Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9564 -05- 9672.000 Parcel #: 099554 0052 Application #: 11 -5 -27257 Subdivision:
Applicant Name: Ernesto & Kathryn Florez
Address: 235 Gainsborough Lane Cameron, NC 28326
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to drilled in Well Area
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
Casing
From 1 To 182
Diameter: 4_5 Material
From To
Grouting Inspection Witnessed Date _
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 8/18/2011 Application #:11 -5 -27257 Well Contractor: Bills Well
Applicant Name: Ernesto & Katbryn Florez
Address: 235 Gainsborough Lane Cameron, NC 28326
Diiections to Site: 27 west to 24/27 turn right then turn left on Hillman Grove Rd. then turn right on Gainsborough lane
Use of Well: sfd Date Drilled: 8/11/2011 Total Depth: 350 ft Replacement Well? x Yes ❑ No
Static Water Level: 200 ft Top of Casing is 12 in. above surface. Yield: 3 gpm at ft.
Disinfection: Type hth Amount
Water Zone (depth)
From 182 To 350
From To
From To
Inspector: bm
Remarks:
Date
pvc Thickness: sdr17
Diameter: Material: Thickness
From To
Diameter: Material: Thickness
On Hold Date: Release Date: 8/18/2011
Well Head Information
Casing Height: 12in (above finished grade) Access Port: yes Vent Stack: }_es
Well ID Tag: yes Pump ID Tag: yes Sampling Tap: }_es
Sample Taken? x Yes ❑ No Well Head properly sealed:
Grout
From 0 To 24
Material: cement Method: op ured
From To
_ Material: Method:
From To
Material: Method:
Backflow Preventer:
Remarks:
Authorized State Agen �,.� ��f Date
See Attachment for completion sketch
Application #:11 -5 -27257 Applicant Name: Ernesto & Kathryn Florez Subdivision: Lot #:
Well Construction Sketch
Home
Septic
.4--- -Tank
D Septic
Building R Drain Field
I
V
Well Area 80 feet
Well Completion Sketch
Home
Septic
F1 4 -Tank
D Septic
Building R Drain Field
I
V
New Weller 80 feet