Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0596-9711735.000 Parcel #: 06 1506 0063 01 Application #: 17-5-41987 Subdivision:
Applicant Name: Joseph Bain
Address: 3833 Rusty Rail Rd. Fayetteville NC, 28312
Type of Facility Served by Well: SFD
Sewage System: 24% Reduction System
Permit Conditions: Warren Road (SR 1741)
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 inc ding location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State
Grouting Inspection Wfttfes
❑ Grouting self -certified by
See attachment for construction sketch
Date�'%3 —f -7
_ Date _
Yes ❑ No
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address:
Directions to Site:
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From _ To
From _ To _
From To
Date Drilled: Total Depth: _ Replacement Well? ❑ Yes ❑ No
Top of Casing is in. above surface. Yield: gpm at ft.
Amount
Casing
From To _
Diameter: Material: Thickness:
From _ To
Diameter: Material: _ Thickness:
From To
Diameter: Material: Thickness:
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
Grout
From 0 To _
Material: Method: _
From To _
Material: Method:
From To
Material: Method:
Vent Stack: _
Backflow Preventer:
Application #:17-5-41987
Well Construction Sketch
Applicant Name: Joseph Bain Subdivision: Lot 9:
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Well Completion Sketch
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