New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
p6w-74- 0Y-C4°'71f-CV"-0�- 37'I
PIN #: 4354 Parcel #: _ Application #: Subdivision: _ Lot #:
Applicant Name:L �%+(
Address: MI (;-Vr
7
Type of Facility Served by Well: SFD
Sewage System: _Z-0/0 &11_
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
Qoopes-
Authorized State A t Date
Grouting Inspection essed 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
Date Drilled: Total Depth: Replacement Well? ❑ Yes ❑ No
Top of Casing is in. above surface. Yield: gpm at
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: Lot #:
Well Completion Sketch