New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0596-97-4107.000 Parcel #: 061506 0066 02 Application #: 16-5-38364 Subdivision: _ Lot #: 5
Applicant Name: Signature Home Builders
Address:
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
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 Date q—xv— / &
Grouting Inspection Wi inessed 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
(deoth)
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: Vent Stack:
Well ID Tag: _ Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Application #:16-5-38364 Applicant Name: Signature Home Builders Subdivision: Lot #: 5
Well Construction Sketch
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L I iY �_-
2b
Well Completion Sketch