New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
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7rZ3yo66y�yZ5� TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: JW Subdivision: C Lot #: Z
Applicant Name: Lr'l�.Gp" fel&I �/
Address: –Wey NINF– C.. i'r' tLisB,•L 2752 /
Type of Facility Served by Well: SFD
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
Authorized State A nt Date
Grouting Inspection tnessed 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
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
See Attachment for completion sketch
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Application #: Applicant Name: S t division: 4jnfg�� Lot #: Z
Well Construction Sketch
Well Completion Sketch