Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1611-46-2186.000 Parcel #: 071611 0031 10 Application #: 17-5-42309 Subdivision: S&B Subdivision
Applicant Name: David Alejandro Sanchez -Lop
Address: 5355 Bailey Cross Roads Rd. Benson, NC 27504
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Johnston County Road (SR 155 1) Lot 5
Lot #: 5
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 Widessed
❑ Grouting self -certified by driller GW -1 provided?
See attachment for construction sketch
Date /b -S"-17
_ 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)
Casine
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 #:17-5-42309 Applicant Name: David Alejandro Sanchez -Lopez Subdivision: S&B Subdivision Lot #: 5
Well Construction Sketch
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Well Completion Sketch