New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1519-07-6125.000 Parcel #: Application #: 16-5-38404 Subdivision:
Applicant Name: Southeastern Construction
Address: po box 157 Buies Creek N.C. 27506
Type of Facility Served by Well: SFD
Sewage System: 25% Red
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 Ag t /rDate
Grouting Inspection Wi ssed 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
L] No
Static Water
Level:
Top of Casing is
_ in. above
surface. Yield:
_ gpm at
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: 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 #:16-5-38404 Applicant Name: Southeastern Construction Subdivision: Lot M
Well Construction Sketch
7P, -
i
W
vS3 A-r►,�
Well Completion Sketch