New Well PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0635-56-3430.000 Parcel 050635 0315 01 Application 10-5-23624 Subdivision: Benny Sears Lot 5
Applicant Name: Charles L. Galloway
Address: 104 Rudolph Rd. Dunn, NC 28334
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: WELL TO BE DRILLED IN AREA PERMITED
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 X
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)
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:
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 Date
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:10-5-23624 Applicant Name: Charles L. Galloway Subdivision: Benny Sears Lot 5
Well Construction Sketch
90 FEET
FROM
PROPERTY
LINE
DRIVE WA
FUTURE
GARAGE
100 FEET WELL
AREA
Well Completion Sketch