New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0680-71-6093.000 Parcel 07-0680-0025-02 Application 10-5-24925 Subdivision:
Lot
Applicant Name: Randall Max GregoryAddress: 1350 Fleming RD Coats N.C. 27521
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: 100 feet off of existing septic system
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 Agei',~~ C`` /T 6.~ at%~-+S
Date 8 - G ;,e
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)
Casing
Grout
From
To
From
To
From 0 To
From
To
Diameter:
Material: Thickness:
Material: Method:
From
To
From
To
From To
Diameter:
Material: Thickness:
Material: Method:
From
To
From To
Diameter:
Material: Thickness:
Material: Method:
Inspector:
On Hold Date:
Release Date:
Remarks:
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:
Vent Stack:
Backflow Preventer:
Remarks
Authorized State Agent
Date
See Attachment for completion sketch
Well Construction Sketch
Well Completion Sketch
441
i'►'I r'~x
Application ZcAZs" Applicant Name 6e"O (Subdivision: Lot