Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1602 33 2610 Parcel #: 07 1602 0108 Application #: 16-5-39262RR Subdivision:
Applicant Name: Esmeralda Espinoza
Address: 6344 Wimberly Rd. Willow Springs NC 27592
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location: Lot 3 Chasbee Ln (Abattoir Rd )
Lot #: 3
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 cation of structures and appurtenance) or modification in use of the well, may
subject this Permit to1,�
Authorized State Ag t�essed
r iCa.. Date
<-Z
3/—� 7
Grouting Inspection Wi 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? EIYes
ElNo
Static Water
Level:
_ Top of Casing is
_ in. above
surface. Yield:
gpm at
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 #:16-5-39262RR Applicant Name: Esmeralda Espinoza Subdivision:
Well Construction Sketch
Well Completion Sketch
Lot #: 3
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