New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
4"5-2.- 09-OW3 4-5
PIN #:4443 .oso Parcel #: &g a! Application #: _ Subdivision: _ Lot #:
Applicant Name:J'KLIp
Address: 2Zy F_ �?it;, & 6T F t/. N.C.
Type of Facility Served by Well: SFD
Sewage System: LS�L,i�pL_
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
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r
Authorized State Ag oc-.i> t <s Date
Grouting Inspection Wi essed 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)
Casin
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 Agent Date
See Attachment for completion sketch
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Application 39433 Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch