New Well Authorization to Construct PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0612-49-4726.000 Parcel #: 13 0602 0139 08 Application #: 17-5-40947R Subdivision: River Ridge Lot #: 4B
Applicant Name: Matthew Porter
Address: 103 Mystic Lane Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Lot 413 River Ridge Drive
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 str�yctures and appurtenance) or modification in use of the well, may
subject this Permit to revocation � � �� �� /j tfs
Lei PSS
Authorized State Agen Date �"S /7
Grouting Inspection I essed 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)
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
See Attachment for completion sketch
Application #:17-5-40947R Applicant Name: Matthew Porter Subdivision: River Ridge Lot M 4B
Well Construction Sketch
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