New Well Authorization to Constructa6L5--61-170 t(.000
HARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: _ Applic#,L- (ow
Applicant Name: *-c49-Q/-5;�
Address:—q�a
Type of Facility Served by Well: SFD Vv
Sewage System: —'Cx� ZM
Permit Conditions:
Subdivision: _ Lot #: S�
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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
51 'Ag/sW9
Authorized State ent '(�Aa„(. % 75 Date
Grouting Inspection Witnessed 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: -F—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)
From _ To
From To _
From To
Inspector:
Remarks:
Casing
From To _
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
On Hold Date: Release Date:
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:
Grout
From 0 To _
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Authorized State Agent Date
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #: Applicant Name: Subdivision: Lot #:
1
Well Construction Sketch ~
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Well Completion Sketch