New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0691-52-9574.000 Parcel #: 07-0690-0130-04 Application #: 16-5-40437 Subdivision: N/A Lot #: 4
Applicant Name: Maria Perez
Address: Lot 4 NC 55W
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
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
Authorized State AgettL�15" Date /- Zo - /7
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:
Static Water Leve—l:
Disinfection: Type
Water Zone
(depth)
From _
To
From _
To
From
To
Inspector:
Remarks:
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Top of Casing is
_ in. above
surface. Yield:
gpm at _ ft.
Amount
Casin¢
Grout
From To
_
From 0 To
Diameter:
Material:
Thickness:
Material:
Method:
From To
From
To
Diameter:
Material: _
Thickness:
Material:
Method: _
From To
From
To _
Diameter:
Material:
Thickness:
Material:
Method:
On Hold Date:
Release Date:
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
Date
Application #:16-5-40437
Well Construction Sketch
Applicant Name: Maria Perez Subdivision: N/A Lot #: 4
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Well Completion Sketch
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