New Well PermitHARNETT PARTMENT OF PUBLIC HEALTH PERM
TO CONSIxXCT A DRINKING WATER SUPPLY WELD.
PIN #: 0643 -09- 77737.000 Parcel #: 08- 0643 - 0014 -07 Application #: 10 -5 -25626 Subdivision: Lot #:
Applicant Name: Mark Van De Hey
Address: 904 Cotton Rd F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction system
Permit Conditions: May Be able to get out of pump if plumbing is stubbed properly
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 /2- /ti( -/0
Grouting Inspection Wi nessed 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
Casin
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 f
Casing Height: ` (above finished grade) Access Port: Vent Stack: s/
Well ID Tag: V Pump ID Tag: Sampling Tap: - Backflow Preventer: ✓ !
Sample Taken'? ❑ No Well Head properly sealedKz
Remarks: c�
Authorized State Age Date < Y-13
f, —
See Attachment for comple `on sketch
Application #:10 -5 -25626
Well Construction Sketch
W,e,t1
,(�yS
o ><
no-4 ,
Well Completion Sketch
Applicant Nam lark Van De Hey
a`
boa
L
3 I
J
�b0
Subdivision: Lot #:
1 �"a
b
0 �
bc' `
tT�