New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 16-5-5-37869
Applicant Name: Jeremy Thomas
Address: 412 Bailey Thomas Rd. Sanford, NC 27332
Type of Facility Served by Well: SFD
Sewage System: 25 % Reduction System
Permit Conditions: Well to be drilled in Well Area
Subdivision: 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 torevocation
Authorized State Agent/acs„�c� o , �f H% Date Z It 2a [ (o
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)
Casine
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:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:16-5-37869 Applicant Name: Jeremy Thomas Subdivision: Lot #:
Well Construction Sketch
Septic
Tank
1
100 ft. --0
Well Area Septic drain field
Home and repair area
To Bailey Thomas Rd.
Well Completion Sketch