New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
0517-33- p1 o536 w-5-4843 /#pt/Br
PIN #:45 .� Parcel #: 002-( Application #: _ Subdivision: _gqp Lot #: LY
Applicant Name: K�bC1L4 A)p,�-
Address:J1� ' /K,�,�q��&,ue -�'.u;,,Sl.y{tF i11. c . 2(d3g�
Type of Facility Served by Well: SFD
Sewage System: Z� , ,_ �'O�t ✓tr%py,/�
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 ent// Date
Grouting Inspection W' rtssed 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
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
11.-s-
Application #: 32&13 Applicant Name: IJO & Subdivision � Lot #: -Qj[
Well Construction Sketch
Well Completion Sketch