New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0643-09-77737.000 Parcel 08-0643-0014-07 Application 10-5-25626 Subdivision: Lot
Applicant Name: Mark Van De Hey
Address: 904 Cotton Rd F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reductionsystem
Permit Conditions: May Be able to get out of pump if plumbing is stubbed properly
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 Age t Date
Grouting Inspection Witnessed 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:
Casing
From To
Diameter: Material
From To
Diameter: Material
From To
Diameter: Material
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 Date
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:10-5-25626
Well Construction Sketch
Applicant Name: Mark Van De Hey Subdivision: Lot
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Well Completion Sketch