New Well Authorization to Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-35566
Applicant Name: Scott C. Brown
Address: 245 Cooper Store Rd. Sanford, NC 27322
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in Well Area
Subdivision: Weswood Lot #: 16
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 Permitto rev ation
�a
Authorized State Agentz: �'� Com// 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: 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
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
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #: 15-5-35566 Applicant Name: Scott C. Brown Subdivision: Weswood Lot #: 16
Well Construction Sketch
Existing
Septic
System
Existing
House
Foundation
100 ft.
rWell
Outlaw Ln
Well Completion Sketch