New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: Application # 3S14L IQ Subdivision: Lot #:
Applicant Name: /7d
Address: X33
Type of Facility Served by Well: SFD
Sewage System: --2s-p �
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 ^9
Authorized State Ag t �--s G J Date y� " Ito
Grouting Inspection Wi 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: _
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To
From To
From To
Inspector: _
Remarks:
Date Drilled: -Total Depth: Replacement Well? ❑ Yes ❑ No
Top of Casing is in. above surface. Yield: gpm at
Amount
Casing
From
To _
Diameter:
_ Material: _ Thickness:
From
To
Diameter:
Material: _ Thickness: _
From
To _
Diameter:
Material: Thickness:
On Hold Date:
Release Date:
Well Head Information
Casing Height: (above finished grade) Access Port:
Well ID Tag: _ Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Grout
From 0 To
Material: Method:
From To
Material: _ Method: _
From To _
Material: Method:
Vent Stack: _
Backflow Preventer:
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Application #: Applicant Name: Subdivision:
Well Construction Sketch
Well Completion Sketch
Lot #: