Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0549-45-8718.000 Parcel #: 100549120321 Application #: 17-5-41738 Subdivision: Lot #:
Applicant Name: Kenneth R. McKoy
Address: 874 Samuel McKoy Ln. (NC 27 W.)
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: 100ft. Setback off New Septic and Existing Septic
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
Grouting Inspection M (latssed 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
Grout
From _ To _
From 0 To
Diameter: _ Material: _ Thickness:
Material: Method:
From To
From To _
Diameter: Material: _ Thickness:
Material: Method:
From To
From To _
Diameter: Material: Thickness:
Material: Method:
On Hold Date: Release Date:
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 Date
See Attachment for completion sketch
Application #:17-5-41738
Well Construction Sketch
Applicant Name: Kenneth R. McKoy Subdivision: Lot #:
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Well Completion Sketch
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Well Completion Sketch