New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
/to'S 3wl
PIN #: Parcel #: Application #: _ Subdivision: _ Lot #:
/_
Applicant Name: G 6e�Vly�
Address: _
Type of Facility Served by Well: SSF�D�
Sewage System:
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 QiZ D to �- / 0
Grouting Inspection Witnessed 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: _
Static Water Level: _
Disinfection: Type
Water Zone
(depth)
From _
To
From _
To
From _
To
Inspector: _
Remarks:
Date Drilled: —CC
Total Depth: Replacement Well? El Yes [—]No
Top of Casing is _ in. above surface. Yield: _ gpm at _ ft.
Amount
Casing
From To _
Diameter: _ Material: _ Thickness:
From _ To
Diameter: _
From _ To
Diameter:
On Hold Date:
Material: Thickness:
Material: _ Thickness:
Release Date:
Grout
From 0 To _
Material: Method:
From _ To
Material: Method: _
From _ To _
Material: Method:
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
l6-�-,3h3s1 ��� Lu,✓�
Application #: Applic nt Name: Subdivision: Lot #:
Well Completion Sketch