Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0633-28-0827.000 Parcel #: 050633020903 Application #: 17-5-41554 Subdivision:
Applicant Name: Dennis Patten
Address: 1260 Cokesbury Road Fupuav-Varina. NC 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
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
Authorized State
Grouting Inspection Witiressed
❑ Grouting self -certified by driller GW -1
See attachment for construction sketch
Date g' 7 - /7
Date _
771 No
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
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
See Attachment for completion sketch
Date
Application #:17-5-41554
Well Construction Sketch
Applicant Name: Dennis Patten Subdivision: Lot 0:
1
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Well Completion Sketch