Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
17Symv
PIN #: Parcel #: Application #: Subdivision: Lot #:A
Applicant Name:
Address:yoc
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M*AType of Facility Served by Well: SFDsd>J t1'. 2�7 Z %
Sewage System: 5�� Z S -C-'4'
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 revocation
Authorized State ADate % —G —!
Grouting Inspection Witt Qed 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)
Casin¢
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:
r/-J- I I ) K v n- nvI3-,wn7w
Application #: Applica t Name: Subdivision:
Well Construction Sketch
Well Completion Sketch
Lot #: