New Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN # 0594-18-1224-000 Parcel 02-0594-0102-01 Application 12-5-28652 Subdivision:
A " mt Name: Alex & Heather Dorman
Ak ~ ss: 4000 N.C. HWY 82 Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Lot
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 Ag t G Date
Grouting Inspection nessed Date _
❑ Grouting self-certified by driller GW-1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 6-4-z-r L. Application ZQ6,57-7 Well Contractor: 5v~-
J` Cocant Name:
Address:
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To _
From To _
From To
Inspector:
Remarks
Date Drilled: Total Depth: ke ent Well? ❑ Yes ❑ No
Top of Casing is in. above surface eld: gpm at ft.
Amount 0 Casing Grout
From To J From 0 To
Diameter: at 1: Thickness: Material: Method:
rom To From To
meter: Material: Thickness: Material: Method:
V"Drom To From To
Diameter: Material: Thickness: Material: Method:
On Hold Date: Release Date:
Well Head Information
Casing Height: I2. (above finished grade) Access Port: Vent Stack:
Well ID Tag: Pu ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes YNo Well Head properly sealed:
Remarks:
Authorized State Ag Date 2 Z
See Attachment for completion sketch
9'-w -/Z
2 Applicant Name: Alex & Heather Dorman Subdivision: Lot
Sketch
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F ( ompletion Sketch
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