Well CompletionHARNETI' DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #:45_U.•" Parcel #:dOq d! Application #:Ya _ Subdivision: _ Lot #:
Applicant Name: 7a�ty
Address: -M F_ VW & -t r F ✓.N,C. M,& C
Type of Facility Served by Well: SFD
Sewage System: Z jobpLrck-J-_
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
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Authorized State Ag t C-. Date `P-Z/�7/-
Grouting Inspection Wi essed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date:/U61 f e .Application #: )$K5> 3 Well Contractor:u—
Applicant Name:
Address: A
Directions to Site:
Use of Well: _ Date Drilled: Total Depth: Replacement Well'? El Yes E-1No
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:
Thickness:
Thickness:
Thickness:
Grout
From 0 To
Material: Method:
From _ To _
Material: Method:
From To
Material: Method:
Well Head Information /
CasingHeight: d' (above finished grade) Access Port: / / Vent Stack:
Well ID Tag: Pump ID Tag: Sampling Tap: / Backflow Preventer. _
Sample Taken? EiYes ❑ No Well Head properly sealed:
Remarks: _
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Authorized State Ag t Date / Z--70 `. /(r
See Attachment for compl on sketch
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Application a:39v33 Applicant Name: Subdivision_ Lot 8:
Well Construction Sketch
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Well Completion Sketch
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