Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 1506-28-1461.000 Parcel 06-1506-0049 Application 11-5-27335 Subdivision:
Applicant Name: Belinda Faulkner
Address: 781 Raiford Rd Erwin N.C.
Type of Facility Served by Well: SFD
Sewage System: Conventional
Permit Conditions:
Lot par#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 Age tF_- Date
Grouting Inspection Witnes - _ Date ~3Y1 /
❑ Grouting self-certified by qdrV!--
GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: /a Application 2 -7 3'75°'Well Contractor:
Applicant Name:
yL
Address:
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To _
From To _
From To
Inspector:
Remarks:
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Top of Casing is
in. above
surface. Yield:
gpm at ft.
Amount
Casing
Grout
From To
From 0 To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
On Hold Date:
Release Date:
Well Head Information
Casing Height: (above finished grade) Access Port: f N
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken. [27Yes ❑ No Well Head properly sealed:
Vent Stack: f
Backflow Preventer:
Remarks:
Authorized State A nt~ Date'
_t-
See Attachment for co etion sketch
Application #:11-5-27335
Well Construction Sketch
-Applicant Name: Belinda Faulkner Subdivision. Lot # Par#A
/whet-4
cmc 96
Well Completion Sketch