Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: Subdivision: _ Lot #: _
P -Iicant Name. t1 4-- q - T/i1 p
ess:a
Type of Facility Served by Well: SFD
Sewage System:
Permit Conditions:
`-1 A
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 StateDate-
t.
Gr ting InspectionWi used' " Date �3130//
Grouting self -certified by driller GW -1 provided? es ❑ No
See attachment for construction sketch
Remarks
Well Head Information
Casing Height: I Z'., (above finished grade) Access Port: ✓ Vent Stack: ✓
Well ID Tag: _/ Pump ID Tag: V� Sampling Tap: _I Backflow Preventer: ✓
Sample Taken? [yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for
Date
WELL CERTIFICATE OF COMPLETION
Date: 03/3o/(Z
Application
#: Well
Contractor. �� h' • j...�.ICs„K��,
icant Name: _
Andress: _
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)
Casine
Grout
From _ To _
From _
To
From 0 To
From _ To'—
Diameter:
_ Material: _ Thickness:
-Material:
_
From _ To _
From _
To _
From
_Method: _
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: I Z'., (above finished grade) Access Port: ✓ Vent Stack: ✓
Well ID Tag: _/ Pump ID Tag: V� Sampling Tap: _I Backflow Preventer: ✓
Sample Taken? [yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for
Date
11.7'-.i-. f - /wYrwS
Application #: Ap licant Nametqr Subdivision:
Well Construction Sketch
Lot #:
Completion Sketch
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