New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9563-95-0258.000 Parcel #: 0995630049 Application #: 16-5-39145 Subdivision: Imperial Ranchette Lot #: 7&8
Applicant Name: Philip Shore
Address: 3860 Marks RD Cameron N.C. 28326
Type of Facility Served by Well: SWMH
Sewage System: EXISTING
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 A`dD a '7—Z0 /(P
Grouting Inspection Wit ssed 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)
Casin¢
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 #:16-5-39145
Well Construction Sketch
Well Completion Sketch
Applicant Name: Philip Shore Subdivision: Imperial Ranchette Lot #: 7&8
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