Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9575 -08- 4204.000 Parcel #: 09 9565 0115 03 Application #: 11 -5 -27379 Subdivision:
Applicant Name: Douglas Wayne Mangum
Address: 132 Trent Dr. Cameron. NC 28326
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in well area
Lot #: T-3 -A
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
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 -27379
Well Contractor: Jackson Well Drilling
Applicant Name: Wayne Mangum
Address: 132 Trent. Dr. Cameron, NC 27546
Directions to Site: 27 west turn left on 24/27 to Trent Dr. turn left
Use of Well: sfd Date Drilled: 8/19/2011 Total Depth: 600 ft Replacement Well? x Yes ❑ No
Static Water Level: 130 ft Top of Casing is 12 in. above surface. Yield: 3 gpm at ft.
Disinfection: Type hth Amount 32 oz
Water Zone (depth)
From 421 To 424
From To _
From To
Inspector: bm
Remarks:
Casing
From 0 To 180 ft
Diameter: 6 in Material
From To
pvc Thickness: sr 21
Diameter: Material: Thickness
From To
Diameter: Material: Thickness
On Hold Date: Release Date: 9/13/2011
Grout
From 0 To 30 ft
Material: sand/cement Method: >l our
From To
Material: Method: _
From To
Material: Method:
Well Head Informationyes
Casing Height: 12 in (above finished grade) Access Port: }_es Vent Stack:
Well ID Tag: �esPump ID Tag: }_es Sampling Tap: yes Backflow Preventer:
Sample Taken? ❑ Yes x No Well Head properly sealed: yes
Remarks:
Authorized State Agent w Date 11-7
See Attachment for completion sketch
Application #:11 -5 -27379 Applicant Name: Douglas Wayne Mangum Subdivision: Lot #: T -3 -A
Well Construction Sketch
Septic
system
H
O
M
E
® H
1 \ O
M Septic
Existing 50 ft. E system
well — —►
Well Area 50+ ft. P.
I
Well Completion Sketch
Septic
system
H
O
M
E
Existing 50 ft.
well ----►
New Well —► O
H
O
M Septic
E system
50+ ft.