New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
d*4a10o14ott 13-5 -
PIN #: Parcel #: _ Application #: -71M Subdivision: _ Lot #: 5/4
Applicant Name: 7N AiK
Address: ASO JN;0�
Type of Facility Served by Well: SFD
Sewage System: --L—R � peals
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 Ag t Z Date
Grouting Inspection Wi nessed Date
❑ Grouting self -certified by driller GW -I 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 #: Applicant✓Name: Subdivision: Lot #: 6-4
M"1 914
Well Construction Sketch
Well Completion Sketch