Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: 13 0519 0132 Application #: 11 -5 -27494 Subdivision:
Applicant Name: Mark K. Meredith
Address: 8374 McDougald Rd. Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions:
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
x Grouting self - certified by driller GW -1 provided? x Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 9/13/2011 Application #:11 -5 -27494
Well Contractor: Jackson Well Drilling
Applicant Name: Mark K. Meredith
Address: 8374 McDougald Rd. Lillington, NC 27546
Directions to Site: old 421 to McDougald Rd go to 8374 McDougald Rd
Use of Well: sfd Date Drilled: 9/9/2011 Total Depth: 200 ft. Replacement Well? x Yes ❑ No
Static Water Level: 25 ft. Top of Casing is 12 in. above surface. Yield: 10 gpm at ft.
Disinfection: Type hth Amount 16 oz
Water Zone (depth) Casing
From 165 To 168 From 0 To 120
From To Diameter: 4 in Material: pvc Thickness: sch 40
From To From To
Diameter: Material: Thickness: _
From To
Diameter: Material: Thickness:
Inspector: bm On Hold Date: Release Date: 9/13/2011
Remarks
Well Head Information
Casing Height: 12 in (above finished grade) Access Port: yes Vent Stack: yes
Well ID Tag: yes Pump ID Tag: yes Sampling Tap: yes
Sample Taken? ❑ Yes x No Well Head properly sealed: yes
Grout
From 0 To 25 ft
Material: sand/cement Method: pour
From To
Material: Method: _
From To
Material: Method:
Backflow Preventer:
Remarks: //
Authorized State Agent �� "v Date c //; xr-
See Attachment for completion sketch
Application #:11 -5 -27494 Applicant Name: Mark K. Meredith Subdivision: Lot #:
Well Construction Sketch
M
C
D
O
U
New
G
Area of
H
Well
A
Septic
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L
System
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Existing
D
E
100 ft. Well
R
WELL
D
OLD AREA
/
drive
HOUSE
Well Completion Sketch
M
C
D
O
U
New
G
Area of
H
Well
A
Septic
/
L
System
O
Existing
D
E
100 ft. -__ Well
R
D
OLD
/
drive
HOUSE