Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0643 19 1737 000 Parcel #: 08 0643 0014 02 Application #: 17-540996 Subdivision: Craven Langston
Applicant Name: Micahel & Jessica Altier
Address: Gentle Valley Ln (Cotton Rd - SR 1426)
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Lot #: 2
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
Grouting Inspection messed
❑ Grouting self -certified by driller
See attachment for construction sketch
Date Y-5'—/7
_ Date _
Yes ❑ No
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address: _
Directions to Site:
Use of Well: _
Date Drilled: _
Total Depth:
_ Replacement Well? El Yes
[-INo
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: _ Vent Stack: _
Well ID Tag: _ Pump ID Tag: _ Sampling Tap: _ Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
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Application#: Applicant Name: AlOr Subdivision:
Well Construction Sketch
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Well Completion Sketch
Lot #: i
I
1
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