Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
O(0199 -33-4-1s,71, It- S -3T7'7
PIN #: Parcel #: Application #: _ Subdivision: Lot #: _
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Applicant Name: TUay 'lagZ
Address: �sCa >h6 lZb
Type of Facility Served by Well: SFS 1jW A4-"
Sewage System: Z3
Permit Conditions: X001 z)� I"+,- W e -i
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 Stat gent Z Date 2 b 7
Grouting Inspection ssed 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
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 Agent Date
See Attachment for completion sketch
lto-S-39757
Application #: Applicant Name:
Well Construction Sketch
Well Completion Sketch
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Subdivision: Lot #: l0
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