New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0692-58-0920.000 Parcel #: 040692 0039 Application #: 15-5-36010 Subdivision:
Applicant Name: Paul Rian Dupree & Danielle Dupree
Address: PO Box 1612 Angier N.C. 27501
Type of Facility Served by Well: MOD
Sewage System: Pump to 25% Reduction System
Permit Conditions:
Lot #: 3
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 Date gs �iZ Y
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)
CasinIZ
From
To
From _
From
To
Diameter:
From
To
From _
Diameter:
From _
Diameter:
Inspector: On Hold Date:
Remarks
Grout
To From 0 To
Material: Thickness: Material: Method:
To From To
_ Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
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
C
Vent Stack:
Backflow Preventer:
Application #:15-5-36010 Applicant Name: Paul Rian Dupree & Danielle Dupree Subdivision: Lot #: 3
Well Construction Sketch
Well Completion Sketch