New Well Completion PermitHARNETT 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:
'icant Name: Dwight & Linda Briggs
.-,_...ress: 9524 NC Hwv 42 Hollv Snrines NC 27540
Type of Facility Served by Well: SFD
Sewage System: Existing
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 Age t 6_111M* Date 10-24-1Z
Grouting Inspection Wit essed Date
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
icant 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)
Casing
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:
ii lRi
Remarks:
1?. Co
�r
Well Head Information
Casing Height: J- (above
finished grade)
Access Port:
Vent
Stack: r'
Well ID Tag: —�
Pump ID Tag:
Sampling Tap:
/'�
Backflow Preventer:
Sample Taken? s
❑ No Well Head
properly sealed:
P arks: ,�q %
Authorized State Ag Date ` ' /0 9
See Attachment for compl Ion sketch
ix -(Z
Application #:12 -5 -29960 Applicant Name: Dwight & Linda Briggs Subdivision: Lot #:
Well Construction Sketch
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•HARNETT COUNTY HEALTH DEPARTMENT N2 --6822,
ENVIRONMENTAL HEALTH SECTION
Distance From Well: /OD ft.
Following are the specifications for the sewage disposal system on above captioned property.
Type of system: 6S• Conventional ❑ Other
Size of tank: Septic Tank: 1600 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches q of each ditch 1W ft. ditches _ ft. ditches in.
French Drain: Linear feet �f
Date:
PERMIT NO.
•� a
Inspected by:: ,,
Environmental Health Specialist
p 1'i