New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: _ Application #: Subdivision: Lot #:
Applicant Name:/0NAr^ `
Address: JJ
Type of Facility Served byWell:Well: VID - /Yip DO Lct<,L
Sewage System: —46 Grp le G
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 State6 Date /D-6 �6
Grouting Inspection Wt 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
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Application #: Applican Name: Subdivision: Lot #:
Well Construction Sketch
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Well
Well Completion Sketch