Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
000 ATO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: Application #: Subdivision: _ Lot #:
Applicant Name: -&AON LMLO
Address: ---M-7 (RIw wt
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Type of Facility Served by Well: SFD
Sewage System: _ J(� S0'—/
Permit Conditions: OQ
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 Aunt _ 4 - -Q-
Grouting
Q-
Grouting Inspection W&Rdssed Date _
❑ Grouting self -certified by driller GW -I 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)
Casing
From _
To _
From _
From _
To _
Diameter:
From
To _
From
Diameter:
From _
Diameter:
Inspector: _ On Hold Date:
Remarks:
IIP
Material: _ Thickness:
To
Material: _ Thickness:
To _
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:
Application M ApplicantantNaRme-:� _13� Subdivision: Lot #:
lift -
Well Construction Sketch
Well Completion Sketch