New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0588-97-2620.000 Parcel #: 07 0588 0155 02 Application #: 15-5-37479 Subdivision:
Applicant Name: Larry Williford
Address: 129 Wayne Lane Erwin N.0
Type of Facility Served by Well: SFD
Sewage System: Existing
Permit Conditions:
Lot #:
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 A nt z ACJ Date IZ—/b %S
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
(death)
Casing
From
To
From
To
From
To
Diameter:
Material: _
From
To
From
To _
Diameter:
Material: _
From
To _
Diameter:
Material:
Inspector:
On Hold Date:
Release Date:
Remarks:
Grout
From 0 To
Thickness: Material: _ Method:
From To _
Thickness: Material: Method:
From To
Thickness: Material: Method:
Well Head Information
Casing Height: _ (above finished grade) Access Port: Vent Stack:
Well ID Tag: _ Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent Date
See Attachment for completion sketch
Application #:15-5-37479 Applicant Name: Larry Williford Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch