New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
1515=J`l ` Ot^ts(K-ao js� o 1 1`JS
PIN #:yz6'8 Parcel #: _ Application #:89, Subdivision:_ Lot #: —
Applicant Name: J&!(% 6i,40oo
Address: _ro 1.4,
Type of Facility Served by Well: SFD
Sewage System:G?%'0 2P-T�
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 O
Authorized State 4160J 1 a Date
Grouting Inspection Wi nessed 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
See Attachment for completion sketch
Date
6—S — MrK G �
Application M 2111 Apphcan[ Name: Subdivision: Lot N:
Well Construction Sketch
Well Completion Sketch
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