New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
A0000
PIN #: Parcel #: Application Subdivision: CxWK Lot #: Z
Applicant Name:
Address:
Type of Facility Served by Well: SFD J
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 117049
Authorized State AgeC:)Date I)—/—/(o
Grouting Inspection Wit sed 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)
Casing
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
ppl —tion #: 2� � pP S1uA'yL
A icahon #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch