Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 1518-97-0694.000 Parcel 02-1518-0140-08 Application 11-5-26417R Subdivision: ROY DUNN
Lot 2
Applicant Name: James and Jerryline Alston_
Address: 146 Hobson Rd Dunn N.C. 28334
Type of Facility Served by Well: M/H
Sewage System: 25%Reduction System
Permit Conditions:
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 Ag t Date 0~3~/j
Gro Ling Inspection Wa nes Date
Grouting self-certified by dri GW-1 provided? es ❑ 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:
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Well Head Information
Casing Height: ' (above finished grade) Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: /I Sampling Tap: Backflow Preventer:
Sample Taken? ~Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State A ent it Date
See Attachment for completion sketch
Fla54e
Application Applicant Name: Subdivision: Lot
Well Construction Sketch A/5
Well Completion Sketch
5