New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: _ Application #: Subdivision: _ Lot #:
Applicant Name: Z7 -A-<
Address: 2 S ] A14a.tN /16 46wn
Type of Facility Served by Well: SFD
Sewage System: �S r3 %t¢.�$ GL,
Permit Conditions:'?�b CS O'O-c 4'c- '9"
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
,� t7yrtS
Authorized State nt Date
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: 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)
Casine
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
See Attachment for completion sketch
I(0-5 -39943 PAO* i L ej—A-Ck6^ x
Application #: Applicant Name: Subdivision: Lot #:
Well Completion Sketch