New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 9597-58-7974 Parcel
Applicant Name: James A. Jones
Address: 143 Canterbury Rd. Sanford, NC 27332
Type of Facility Served by Well: SFD
Sewage System: pump to conventional
Application 09-5-21567 Subdivision: Lot
Permit Conditions: Well to be 100 ft from septic tank drain field and repair area and 25 ft from building foundation
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
~t
Authorized State Agent Date dl ' Z-ca
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)
Casins
Grout
From
To
From To
From 0 To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
From
To
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
Inspector:
On Hold Date:
Release Date:
Remarks:
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 Agent Date
See Attachment for completion sketch
Application #:09-5-21567 Applicant Name: James A. Jones Subdivision: Lot
Well Construction Sketch
Septic &
Pump Tank 0
Septic
Drain field
100 ft+
DRIVE WAY
Well Completion Sketch