New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
0111 - m — 11, .-35743
PIN #: Parcel #: Application Subdivision: Lot #:
Applicant Name: 01" % r -f 1 per_ a 4ee#�CQ Hav
Address: 211-% JH,t,-'Ip (,t G _ avG
rr ��C.. / 7i75Z-Y
Type of Facility Served by Well: SFB y� J -
Sewage System: Itr—A axl:c
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 i nt D� at :• ��`
Grouting Inspection Wi sed 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
(death)
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 M Applicant Name: Subdivision: Lot M
Well Construction Sketch
Well Completion Sketch