New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0641475112 Parcel#: _
Applicant Name: Drake Homes
Address: 5609 Stewart RD
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
Application #: 16-5-38506 Subdivision: Denton Lot #: 1
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 // R&K
Authorized State Age Date
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
From To _
From
From To _
Diameter:
From To
From
Diameter:
From _
Diameter:
Inspector: On Hold Date:
Remarks:
Grout
To From 0 To
Material: Thickness: Material: _ Method: _
To From To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
Release Date:
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
Date
Application #:16-5-38506 Applicant Name: Drake Homes Subdivision: Denton Lot #: 1
Well Construction Sketch
Well Completion Sketch