Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PF.Pd%M
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0641-58-6198 Parcel # Application 10-5-25663 Subdivision: Joseph Bal=Lot lot B
Applicant Name: Joshua T Baker
Address: Bradlev rd
Type of Facility Served by Welh SFD
Sewage System: 25% Reduction
Permit Conditions:
General Permit Conditions:
• Drinking water supply well construction must meet 15A NCAC 02C.100 rules
• The permitted drmkmg 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 Ag 1 ~ Date 1,Z- -r c7
Grouting Inspection WitnemOdDv- e Date ® 7 /j
❑ Grouting self-certified by GW-1 provided? Yes ❑ No
See attachment for construction sketch
Off WELL cER.cATE oc~
Date: Application well contractor:
Applicant Name-
Address
Directions to Site:
'
TJse of Well: ~ to Drilled: !it Total Depth: 160
Static Water Level: O T Casing is t -Lin. above surface.
Disinfection: Type Amount -LLI Water Zone (depth`)
From To t v
From To
From To
Inspector.
Remarks:
Canna
From D To
Diameter- _6 Material: irk
From To
Diameter.
From To
Diameter.
On Hold Date:
Replace' well? ❑ Y4 ONO
Yield gpm at ft.
Thickness: 1 D
Thickness:
Material: Thickness:
Release Date:
Grout )
From .0
To 1
Material: etbad
From To
Materiah: Method:
From To
Material- Method:
Well Head Information
Casing Height (above finished grade) 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 en Date
See Attachment for co on sketch