New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1518-77-8254.000 Parcel #: 02 1518 0011 11 Application #: 16-5-38224 Subdivision:
Applicant Name: Betty Vollmer/ Dana Mcleod
Address:
Type of Facility Served by Well: DWMH
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 12
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 Das
Grouting Inspection W t sled 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)
Casins
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:
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:16-5-38224 Applicant Name: Betty Vollmer/ Dana Mcleod Subdivision: Lot #: 12
Well Construction Sketch
LJelI x
AI (ZB-jbp
r4J8t 11 2)
t3 —a D5
6, --t
c5t+1�e*'
grx-
-Fks4
Well Completion Sketch