Authorization to construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0517-98-7420.000 Parcel#: 1305270020 Application #: 17-5-41438 Subdivision: _ Lot#:
Applicant Name: Christina Jardine
Address: 2317 Park Summit Blvd Apex, NC 27523
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: 324 Clark Rd. (SR 1129) - Reference Construction Sketch
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 (inc4Wiug loco ' n ofo4cmres and appurtenance) or modification in use of the well, may
subject this Permit to revocation /
Authorized State ent. L /'PL Mf n3[n/ Q Date
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ N_o
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? ElYes F-1No
Static Water Level: Top of Casing is _ in. above surface. Yield: _ gpm at ft.
Disinfection: Type Amount
Water Zone
(depth)
Cosine
From
To
From _
From
To _
Diameter:
From
To
From
Diameter:
From
Diameter:
Inspector: On Hold Date:
Remarks:
we,
Material: Thickness:
To
Material: _ Thickness:
To
Material: Thickness:
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
Grout
From 0 To _
Material: _ Method: _
From To _
Material: _ Method: _
From To _
Material: Method:
Vent Stack:
Backflow Preventer:
Application #:17-5-41438 Applicant Name: Christina Jardine Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch Stf