New Well PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-36761
a. .cant Name: S. Wayne Harrington
Address: 1183 Blanch Johnson Rd. Broadway, NC 27505
Type of Facility Served by Well: SFD
Sewage System: conventional
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 to rev ation ��
Authorized State Agent pro. /� Date
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
t� t WELL CERTIFICATE OF COMPLETION
mmol^ �-
Date: y-13 "14 Application #: * Well Contractor:
ApviicantName:
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:
Casine
From _ To
Diameter: _ Material:
From _ To
Diameter: Material:
From To _
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: _ Method:
From To _
Thickness: Material: Method:
From _ To
Thickness: Material: Method:
Well Head Information /
Casing Height: 1q1 (above finished grade)/ Access Port: / // Vent Stack: _
Well ID Tag: Pump ID Tag: Sampling Tap: ✓ Backflow Preventer: _
Sample Taken? ❑ No Well Head properly sealed: ✓
F rks:
Authorized State Ag Date
See Attachment for comp 4tion sketch
Application #: 15=3--36761
Well Construction Sketch
Applicant Name: S. Wayne Harrington Subdivision: Lot #:
House
H
A
R
R
I
N
G
New Well
T
Area OO
O
N
Efisting
R
well
D
Blanch Johnson Rd.
Iv. _.. Completion Sketch