Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONS'T'RUCT A DRINKING WATER SUPPLY WELL
PIN k; Parcel N: � APPI/� ion p Subdivision: Lot p:
APPlicant Nante: �AVr b �% M C%2 '•
Address: �S7 /1r�0alN J1Jj
Type of Facility Served by Well: SSFFD
Sewage System:
Perot Conditions:
General Permit Conditions:
• Drinking water supply well construction must men 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
subjecl this Peltnil to revocation SIPS
Authorized State Ln, Date
Gro ng Inspection �1'i ased Date
L:jGrouting self -certified by driller GW -I provided? Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Amolicationn: Well Contractor. _jBif-Gto ti We1(a1f+yt7---
Applicant Name. —
Address:
Directions to Si(e:
Use of Well: Date Drilled- Xj-Z-/7 Total Depth: �7!r Replacement Well. ❑ Yes o
static Water level: _LL Top of Casing is I Y;;X. in. above surface. Yield: /0 gpm at, it.
Disinfection: Type d_w!/,: Amount Jya.w/
Water Zone fdellthl F�1Z To /d� From 29M To
From , To
From To -- Diameter: � materia 1: �e.v Thickness: y� Material: / Method: 'ly
From To _ From Q To 14-9-;rFrom , o _
Diameter: ` Material: _ Thickness: Material: _ Method:
From To _ From _ To _
Diameter: Material: _ Thickness: Material: ^ Method:
Inspector.
On Hold Dale: Release Date:
Remarks:
Well head Information
Casing lictghc above finished grade) Accu+ Port: Vent Stuck:
Well ID 1 a: pomp ID Tag' _ Sampling Top: Backflow Prrvenler: _
Sample Taken' Q Yes ❑ NO Well fiend properly sailed:
Remarks:
Date
Authorized Stale ._
ion sketch
1 (o- -399X3 P%'Owb L U s�Gk
Application #: Applicant Name: Subdivision: Lot #:
Well Completion Sketch