New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: Application #: _ Subdivision: — Lot #:
Applicant Name: Y –ft3
Address: s/3 fin, ,a� &A) Z$ 33 Y
Type of Facility Served by Well: SP& W'✓r./k1
Sewage System:�� %1 aaQ
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 A !/ ��4-pj Date%/ -7
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GWA 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 Level:
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
Amount
Casine
From To _
Diameter: Material: Thickness:
From To
Diameter:
From _ To
Diameter:
On Hold Date:
Material: _ Thickness:
Material: Thickness:
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:
Authorized State
See Attachment for completion sketch
Date
Grout
From 0 To _
Material: Method: _
From To _
Material: Method:
From _ To
Material: Method:
Vent Stack: _
Backflow Preventer:
IG -ti —1 t04b i J ohtvNM ��Waur ` `
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch