Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0682-92-9336.000 Parcel 040682-0224-01 Application 11-5-27533K Subdivision: Pointers Creek
Applicant Name: SHC Holdings Inc
Address: 466 Stancil Rd Angier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: 25% RED
Permit Conditions:
Lot 1
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 Agqt y^- - Z Date
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
Inspector:
Remarks:
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
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.
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:11-5-27533 /L Applicant Name: SHC Holdings Inc Subdivision: Pointers Creek Lot 1
Well Construction Sketch
CY2", 7'
Well Completion Sketch
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Harnett Coufity Department of Public Health
Well Construction Permit Application
If the information in the application for a Well Construction Permit is ftzlsified,
changed, or the site is altered, then the Well Construction Permit shall become
invalid
,t APPLICANT INFORMATION
I S.an~ OM M 3R 4013
Annife9nonwnpir _Phone Number
Street Address, City, State, Zip Code
The Applicant must submit a Site Plan The Site Plan is a map/drawing of the property and must show
i existing and/or proposed property lines and easements with dimensions
2 the location of the facility and appurtenance
3 the location for the proposed well
4 the location of existing or proposed sewer lines and/or sewage disposal systems within 100 feet or the proposed well
5 the location of any existing wells within 100 feet of the property surface water bodies
6 above ground and/or underground storage tanks
7 and any other known sources of contamination within 100 feet of the proposed well site
The Applicant shall notify the Harnett County Health Director through or by way of the Harnett County
Division of Environmental Health if any of the following occur prior to well construction
I there is a relocation of the proposed facility
2 there is a change in the intended use of the facility
3 there is a need for installing the waste water system in an area other than indicated on the well permit or
4 there are landscape changed that affect site drainage
Contact information Environmental Health Division - 910-893-7547
PROPERTY INFORMATION
Proposed use of well
Single-Famllyw Multifamily❑ Church ❑ Restaurant ❑ Business ❑ Irrigation ❑
Street Address Subdivision/Lot # ~O%n~ws CxeX
Parcel # o N~o 1B a - a a*~ - o l PIN # . poo
51`
i have thoroughly read and completed this Application and certify that the information provided herein is true complete and
correct to the best of my knowledge and is give in good faith Representatives of the Harnett County Health Department and L
state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable rules 5
d that 1 am solely respo ble or the proper identification and labeling of all property lines underground utility lines and
site accessible so that M. i I can be properly constructed acc tng to the permit
Required Date
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON k- ra In -A 68A- iV
If permits are granted I a ree to conform to all ordinance segd la f the State of North Carolina regulating such work and the specifications of plans submitted
I hereby state that foreg ng ants are accurate and~Urreect t best of my nowledge Permit subject to revocation if false information is provided
(V~ 4-13-11
Signature of Owner or Owners Agent Date
It Is the owner/applicants responsibility to provide the county with any applicable information about the subject property Including but not limited
to boundary information house location underground or overhead easements etc The county or its employees are not responsible for any
Incorrect or missing information that Is contained within these applications "
This application expires 6 months from the Initial date If permits have not been Issued"
Resideribil Land Use Application Page 2 of 2 03/11
NAME -9131 D I APPLICATION #
*This application to be filled out when applying for a septic system inspection
County Health Department Application for Improvement Permit and/or Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID The permit is valid for either 60 months or without expiration
depending upon documentation submitted (Complete site plan = 60 months Complete plat = without expiration)
910 893-7525 option 1 CONFIRMATION #
❑ Environmental Health New Septic System Code 800
• All oroyertv irons must be made visible Place pink property flags on each corner iron of lot Ail property
lines must be clearly flagged approximately every 50 feet between corners
• Place orange house corner flags at each corner of the proposed structure Also flag driveways garages decks
out buildings swimming pools etc Place flags per site plan developed attfor Central Permitting
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property
• If property is thickly wooded Environmental Health requires that you clean out the undergrowth to allow the sod
evaluation to be performed Inspectors should be able to walk freely around site Do notgrade property
• All lots to be addressed withm 10 business days after confirmation $25 00 return trip fee may be incurred
for failure to uncover outlet lid, mark house corners and property lines, etc once lot confirmed ready
• After preparing proposed site call the voice permitting system at 910-893-7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection Please note
confirmation number given at end of recording for proof of request
• Use Click2Gov or IVR to verify results Once approved proceed to Central Permitting for permits
❑ Environmental Health Existinci Tank Inspections Code 800
• Fallow above instructions for placing flags and card on property
• Prepare for inspection by removing sod over outlet end of tank as diagram indicates and lift lid straight up (if
possible) and then put lid back in place (Unless inspection is for a septic tank in a mobile home park)
• 'DO NOT LEAVE LIDS OFF OF SEPTIC TANK
• After uncovering outlet end call the voice permitting system at 910-893-7525 option 1 & select notification permit
if multiple permits then use code 800 for Environmental Health inspection Please note confirmation number
given at end of recording for proof of request
• Use Click2Gov or IVR to hear results Once approved proceed to Central Permitting for remaining permits
SEPTIC
If applying for authorization to construct please indicate desir system type(s) can be ranked in order of preference must choose one
{i) Accepted innovative { Conventional Any
Alternative Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question If the answer is yes applicant MUST ATTACH SUPPORTING DOCUMENTATION
YES
1%4 NO
{_}YES
{ZNO
{_}YES
{ZNO
)YES
IV) NO
{_}YES
{ V} NO
{_}YES
{jt~NO
{_VYES
NO
(_)YES
{ v}0 NO
Does the site contain any Jurisdictional Wetlands?
Do you plan to have an irrigation system now or in the future?
Does or will the building contain any drains? Please explain
Are there any existing wells springs waterlines or Wastewater Systems on this property9
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other Public Agency?
Are there any Easements or Right of Ways on this property?
Does the site contain any existing water cable phone or underground electric lines?
If yes please call No Cuts at 800 632 4949 to locate the lines This is a free service
I Have Read This Application And Certify That The Information Provided Herein Is True, Complete And Correct Authorized County And
State Officials Are Granted Right Of
I Understa t i Am Solely Respons'
The Site A 4%st'lle So That A Complete
To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules
For The Proper Identification And Labeling Of All Property Lines And Corners And Malang
Evaluattan Can Be Performed
PROPERTY OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED)
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DATE
10/10
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