New Well Authorization To ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1600 14 7504.000 Parcel #: 07 1600 0147 02
Applicant Name: Eric Sauer
Address: 1026 Delma Grimes Rd Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: Pump to 25% Reduction
Permit Conditions:
Application #: 13 -5 -31182 Subdivision: 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
a
Authorized State A nt 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: Application #: Well Contractor:
Applicant Name:
Address:
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To _
From To _
From To
Inspector:
Remarks
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Top of Casing is
in. above surface. Yield:
gpm at ft.
Amount
Casing
Grout
From To
From 0 To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material:
Thickness:
Material:
Method:
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
Date
Vent Stack:
Backflow Preventer:
Application #:13 -5 -31182 Applicant Name: Eric Sauer Subdivision: Lot #: 2
Well Construction Sketch
Well Completion Sketch