Well Authorization to Construct PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: Subdivision: 13 -5 -30528 Lot #:
Applicant Name: Harnett County
Address: Nursery Rd
Type of Facility Served by Well: Park
Sewage System: conventional
Permit Conditions: Well to be drilled in Well Area
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 rev cation
Authorized State Agent c Date jG ,Z5 / °«
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:
Casin
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
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 -30528 Applicant Name: Harnett County Subdivision: Lot #:
Well Construction Sketch
Initial & Repair Septic System
Areas W
O
O
D
L
I
Picnic N
Restrooms Shelter 100 ft. E
Well Area
Path
Well Completion Sketch