Authorization to construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1515-09-5589.000 Parcel #: 021505006601 Application #: 17-541700 Subdivision:
Applicant Name: Red Door Homes
Address: 142 Shenstone Blvd Gamer, NC 27529
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location: Chicken Farm Rd. / Dunn-Baersville Rd. (SR 1790)
Lot #:
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, --e «�
Authorized State Agi nt L 1—nqx�.qDate 7-11-1-2
Grouting Inspection itnessed 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)
From _ To
From _ To
From To
Inspector:
Remarks:
Casin
From _ To _
Diameter: _ Material: Thickness: _
From To
Diameter: Material: Thickness:
From _ To
Diameter: Material: Thickness:
On Hold Date: 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 Agent
See Attachment for completion sketch
Grout
From 0 To
Material: _ Method: _
From To _
Material: Method:
From To
Material: Method:
Vent Stack:
Backflow Preventer:
Application #:17-5-41700
Well Construction Sketch
Applicant Name: Red Door Homes Subdivision: Lot #:
Well Completion Sketch
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Well Completion Sketch