Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0692-78-0141.000 Parcel #: 070692 0036 033 Application #: 17-5-42291 Subdivision: Joseph Gerrell Lot #: 1
Applicant Name: Richard & Rebecca Lamv
Address: 3717 Melrose Drive Raleigh, NC 27604
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - 229 Ablitzd Lane Angier, NC 27501
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
i
Authorized State ent ini_� Date `1 -Z e—(7
Grouting Inspection Witnessed
❑ Grouting self -certified by driller GW -1 provided?
See attachment for construction sketch
_ Date _
Yes ❑ 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 _ ft.
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:
Well ID Tag: Pump ID Tag: _ Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack: _
Backflow Preventer:
Application #:17-5-42291 Applicant Name: Richard & Rebecca Lamy Subdivision: Joseph Gerrell Lot #: 1
Well Construction Sketch
Well Completion Sketch
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Well Completion Sketch