Authorization to constuct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0693505050 Parcel #: 040693010301 Application #: 17-540748 Subdivision: Lot #: 1
Applicant Name: Stancil Builders, Inc.
Address: 510 Kirk Adams Road
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
Authorized State Agit t5Dale s !_ %
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
(deuth)
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
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch
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Well Completion Sketch