New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0625 -68- 1826.000 Parcel #: 05- 0625- 0021 -01 Application #: 12 -5 -29960 Subdivision: Lot #:
Applicant Name: Dwight & Linda Briggs
Address: 9524 NC Hwy 42 Holly prings NC 27540
Type of Facility Served by Well: SFD
Sewage System: Existing
Permit Conditions:
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
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Authorized State Age t Date
Grouting Inspection Wit essed Date
F-1 Grouting self - certified by driller GW -1 provided? F-1 Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant 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:
Replacement Well? ❑ Yes
❑ No
Top of Casing is
in. above surface. Yield:
gpm at ft.
Amount
Casing
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: (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,
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #:12 -5 -29960 Applicant Name: Dwight & Linda Briggs
Well Construction Sketch
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Well Completion Sketch
Subdivision: Lot #:
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