New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #:lL_ Parcel #: Aucpl Application #: " Subdivision: 1 Lot #:
Applicant Name: Oo two
Address:lsir4 Qr:{{ La(rx s3�
Type of Facility Served by Well: SFD
Sewage System:L 5 �6 a? o n Sys"
Permit Conditions: Op\\ %60'4 oFF�kC
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 rev�atio� _
Authorized State
Grouting Inspection Wffnessed
❑ Grouting self -certified by driller GW -1 provided?
See attachment for construction sketch
12 /05
_ Date _
Yes ❑ No
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
(death)
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:
Well ID Tag: _ Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack: _
Backflow Preventer:
tb- 4or� 664
Application M Applicant Name: _it, Subdivision: 6n Lot M J—
Well Construction Sketch
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Well Completion Sketch