New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: 0"?Yo•4e•�Application #: Subdivision: Lot #: Z
Applicant Name: -AL_G C.
Address: —32_01 14055r j7X�• G
Type of Facility Served by Well: SFD
Sewage System: —2,-�"lo jlP�
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 Q
Authorized State eat -Date 9r
—Q—/(
Grouting Inspection W 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)
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
Application #: Applicant Name: Subdivision:
Well Construction Sketch
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M.
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Lot #: Z
Well Completion Sketch