COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro NC 27203
LOCAL TELEPHONE NUMBERS
Asheboro: (336) 318-6262 ● Archdale/Trinity: (336) 819-3262
http://www.randolphcountync.gov
Application for Well Permit (EHW 1) Rev. 9/5/2019
APPLICATION FOR WELL PERMIT
If the information in the application for a Well Permit is falsified, changed or the site is altered, then the
Well Permit shall become INVALID. The permit is valid for 60 months from date of issuance.
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Location: ________________________________________________________________________________
Subdivision: ______________________________ Lot number: ______________________________
FACILITY INFORMATION:
Well Proposed Use: ________________________ Filled Areas on Site: ________________________
Number of Connections: _____________________ Easements on Property: _____________________
Number of People Served: ___________________ Any Underground Tanks: ____________________
Number of Existing Wells: ____________________ Any Land Applied Waste: ____________________
Existing Well Type: _________________________ If Yes, Where: _____________________________
Number of Existing Septic Systems: ____________ Restrictions on Groundwater: _________________
Surface Water Body on Site: _________________ Variances Pending: ________________________
TOTAL APPLICATION FEE: _________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
AUTHORIZATION TO PROCEED:
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 entry to conduct necessary inspections to determine
compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification
and labeling of all property lines and corners and making the site accessible so that a complete site evaluation
can be performed.
_______________________________________ _________________________________________
Signature of property owner/legal representative* Date
*You must provide documentation to support claim as owner’s legal representative.
Surface water body on site
Restrictions on groundwater
click to sign
signature
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