Well CompletionHARNETT' 'ARTMENT OF PUBLIC HEALTH PERM
TO CONSTKtJCT A DRINKING WATER SUPPLY WELL
PIN 0682-25-0813.000
Lot 7
Parcel 040682 0348
Applicant Name: Joel Michael Eason
Address: 6420 Johnson Pond Rd F.V. N.C.
Type of Facility Served by Well: SFD
Sewage System:25% Reduction System
Permit Conditions:
Application #:11-5-26631 Subdivision: Mabry
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 AgenC; Date S--10-1(
Grouting Inspection Witness Date 6
❑ Grouting self-certified by drill GW-1 provided? Yes ❑ No
See attachment for construction sketch
11-5"1-
Date: A~3~10 Application#: Z j
WELL CERTIFICATE OF COMPLETION
Well Contractor: ZDd5.1t /v/
Applicant Name:
Address:
Directions to Site: "f
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
Ca- sing
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: I (above finished grade) / Access Port: Vent Stack: /
Well ID Tag: / Pump ID Tag: / Sampling Tap, ,,f Backflow Preventer:
Sample Taken? es ❑ No Well Head properly sealed: ,i`
Remarks:
Authorized State A e t
g Date 16 -3 - j /
See Attachment for completion sketch
P-5-4431 46&1 ria-h--w /aa~o~a
Application Applicant Name: zbdivision:mrrJ Lot
Well Constructi n Sketch
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Well Completion Sketch
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