New Well Completion PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0681 -80- 5678.000 Parcel #: 010681 0001 05 Application #: 12 -5 -30145 Subdivision:
Applicant Name: Marshall Danenbure
Address: 1108 Old Stage RD Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: Conventional
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 Agent Date
Grouting Inspection Witnessed Date _
❑ Grouting self - certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: }2-u °i Z_ 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)
From To
From To
From To
Inspector:
Remarks
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Well Head Information
Casing Height: ! Z' (above finished grade) Access Port: Vent Stack:
Well ID Tag: r Pump ID Tag: Sampling Tap: ✓ Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agen Date A —Z i - I
See Attachment for completion sketch
Application #:12 -5 -30145 Applicant Name: Marshall Danenburg Subdivision: Lot #:
Well Construction Sketch