Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0507 -70- 4385.000 Parcel #: Application #: 11 -5 -27528 Subdivision: Lot #:
Applicant Name: William O. Butler
Address: 200 Ransaw Lane Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions: Well to be drilled in well area
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 _/� cam. G�rT� Date�-2 ( 0 /
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
Ca sing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks:
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 Agent,
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:l 1 -5 -27528
Well Construction Sketch
Applicant Name: William O. Butler Subdivision: Lot #:
Existing
Home
Well Area
I
100 ft. 100 ft.
Proposed
Home D
Septic R
Tank
Septic I
system and V
repair area E
Existing Soil drive
Well Completion Sketch