Authorization to Constuct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9575 47 3981 000 Parcel #: 09 9575 0148 53 Application #: 17-5-41058 Subdivision:
Applicant Name: Laura Raean/Ravael Salzar
Address: Florence Drive (Brooks Mangum Rd.)
Type of Facility Served by Well: SWMH
Sewage System: 25% Reduction
Permit Conditions:
Lot #: 4
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 includi2location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State A ent L �� Ufy(!✓ Date 4
Grouting Inspection withessed 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 #:
Well Construction Sketch
Well Completion Sketch
Applicant Name:
,,O,«cel
Subdivision: Lot #: 4-
\N� a 1
O 1
° i p�arosEv I
a I wE« I
I AREA
/< l7N6 <45r y<Nr
3