Well CompletionHARNETT; PARTMENT OF PUBLIC HEALTH PERT
TO CONS1x.UCT A DRINKING WATER SUPPLY WELL.
PIN #:1538-13-6582.000 Parcel 02-1538-9000-08
Lot
Applicant Name: Kurt Stabler
Address: 3066 Fairground Rd Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System:25% Reduction System
Permit Conditions:
Application #:11-5-26198 Subdivision:
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.
Date
Grouting Inspection Witneswd- Z Date
❑ Grouting self-certified by dri r GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application l l 5' -(~i`~Vell Contractor: .gam
Applicant Name: K~1111-,5-i "1 't,
Address:
Directions to Site: &J e(=t--k
Use of Well: Date Drilled: Total D pt Replacement Well? ❑ Yes ❑ No
Static Water Level: Top of Casing is i . a o 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) r Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken~Yes ❑ No Well Head properly sealed: /
Remarks:
authorized State Ag ut Date
-e Attachment for comp ktion sketch
Application M Applicant Name: ubdivision: Lot M
Well Construction Sketch