Well Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0545 -95- 7120.000 Parcel #: 12 0555 0011 13 Application #: 12 -5 -28302 Subdivision: Carroll Lot #: 2
Applicant Name: Michael Waterstripe
Address: 193 Jerome Lane Linden, NC 28356
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be a minimum of 50 ft. from septic system
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 s-� ,�C Date cZ t l a f zdl Z
Grouting Inspection Witnessed Date
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address:
Directions to Site:
Use of Well: Date Drilled: Total Depth: Replacement Well? ❑ Yes ❑ No
Static Water Level: Top of Casing is in. above surface. Yield: gpm at ft.
Disinfection: Type Amount
Water Zone (depth)
From To _
From To _
From To
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks
On Hold Date: Release Date:
Well Head Information
Casing Height: (above finished grade) Access Port:
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:12 -5 -28302 Applicant Name: Michael Waterstripe Subdivision: Carroll Lot #: 2
Well Construction Sketch
Neighbor's
Drain lines D
R
I
V
Property lin E
100 ft Home
Gat
_--w Drain line
Well Area A-- 50 ft.
ost w/ flag
fence
Well Completion Sketch