New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1505 -07- 6048.000 Parcel #: 061505 0006 Application #: 13 -5 -31906 Subdivision:
Applicant Name: Signature Home Builders
Address: 801 West Cumberland ST Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 2
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 t Date f4 60- 13
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:
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:
Casins
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
See Attachment for completion sketch
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Date
Vent Stack:
Backflow Preventer:
Application #:13 -5 -31906 Applicant Name: Signature Home Builders Subdivision: Lot #: 2
Well Construction Sketch
i
V,
Well Completion Sketch