Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
1 TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0653 89 8738 Parcel #: 08 0653 0108 Application #: 17-5-0040794 Subdivision: Matt & Karin Puna Lot #: 2
Applicant Name: Gary & Shirley Flanary
Address: Shady Brook Ln. (Lafayette Rd - SR 1443)
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
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 revoc n
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Authorized State AgetrtGr�cz ![ Date
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: 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)
Casing
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:
Well ID Tag: _ Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack: _
Backflow Preventer:
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch
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