Authorization to construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0681 31 8544 Parcel #: 110681 0005 09 Application #: 17-541248R Subdivision: _ Lot #:
Applicant Name: Clayton Homes of Sanford
Address: Sheriff Johnson Rd. (SR 1516)
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
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 rev y/LS
Authorized State AROt Date 5- 27-1-7
Grouting Inspection W nessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
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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: Vent Stack: _
Well ID Tag: _ Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent Date
See Attachment for completion sketch
Application M Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch
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