New Well Authorization To ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: — Parcel #: — Application #: Subdivision: Lot #: to
ApplicantName:
Address: /2&'l IJ ry�.4w") -6-1—
Type
TType of Facility Served by Well: SFD
Sewage System: —&L��/�
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 f 'Q
f -GroAuthorized State Ag C_ Date /f—
Grouting
uting Inspection Witfiessed 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)
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 Agent Date
See Attachment for completion sketch
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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p
b
VVII
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Well Completion Sketch