Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
'sem �ZZ�59�6 TO CONSTRUCT A DRINKING WATER SUPPLY WELL
p6�s�oo5"r° aq-s�c�-re
PIN #: Parcel #. _ Application #: _ Subdivision: Lot #: It
Applicant Name: bbz�4
Address: -f-6-1 0
✓ �� .u,c. Z
Type of Facility Served by Well: SFD %�31y
Sewage System: 2&� Xow}a0tru". .
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
^_' p /�
Authorized State Agcy C Date 17
Grouting Inspection Witnessed 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)
From _
To _
From _
To _
From
To
Casint
From To _
Diameter: _ Material: Thickness:
From _ To
Diameter: _ Material: _ Thickness:
From To _
Diameter: Material: Thickness:
Inspector: _ On Hold Date:
Remarks:
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:
Applica i n #5: App scant Name: viR Subdivision: Lo[ #: L
Well Construction Sketch
Well Completion Sketch