Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: _ Subdivision: _ Lot #:
Applicant Name. tl / �- q/ c,+- 7 4 -
Address: d � ( L�S f � L*co- � A -T, G
Type of Facility Served by Well: S.F—D
Sewage 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 revocation
Authorized State Date
Grouting Inspection Wi used 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: _
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 _ ft.
Amount
Casing
From
To _
Diameter:
Material: _ Thickness:
From
To
Diameter:
_ Material: Thickness:
From
To
Diameter:
Material: Thickness:
On Hold Date:
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:
n s 4iCM
Application #:-sApglic=Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch