Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
ori
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
ILuo -09 •'JYi' f-7100-OoZi-" )b -Sr 3gYk9
PIN #: Parcel #: _ Application #: Subdivision: _ Lot #:
Applicant Name: a,*, /0)0 //V� _ZaZ_,
Address:
Type of Facility Served
-bbyy Well: 3F13- and
Sewage System: Jrin
Perot Conditions:
General Permit Conditions:
• Drinking water supply well construction must meet ISA 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 Staleen Date_. 10 -lo 7G
Grouting Inspection Wr ssed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: I Z� 4 atv Application #: Well Contractor: 4
Applicant Name: -ranu-tAit, Ar),�
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 _ fl.
Disinfection: Type _ Amount
Water Zone
(death)
Casing
From _
To
From _
To _
From _
To _
Diameter:
_ Material: _
Thickness:
From
To _
From _
To
Diameter:
Material:
Thickness: _
From
To
Diameter:
Material:
Thickness:
Inspector:
On Hold Date: _
Release Date:
Remarks
Grout
From 0 To
Material: Method:
From _ To
Material: Method: _
From To
Material: Method:
Well Head Infor,/
Casing Heighbove finished grade)�� Access Port: Vent Stack: /
Well ID Tag: Pum D Tag: Sampling Tap: Backflow Preventer.
Sample Taken? ❑ Yes No Well Head properly sealed:
Remarks:
Authorized State ent e Ib Date -P --jet --tr FL
See Attachment for comp 'on sketch
N,6�5MKAr- C1jjj -JW^ o Z44,
Application #: Applican Name: Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch