New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0636 -71 -5084 000 Parcel #: 05- 0626 -0207 Application #: 12 -5 -30132 Subdivision:
Applicant Name: Stanley Cotten
Address: 237 Country Folks LN Holly Springs N.C. 27540
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: 100, off existing well and septic
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 tf {� Date 12
Grouting Inspection Witnessed Date _
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
—12
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)
Casin14
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
i'L �T —3, 0uz Sf �N ►£� Cc�6 �r�
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch