Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0509-24-1202.000 Parcel #: 130509007703
Applicant Name: David Etheridge
Address: 470 Fox Hunters Ln Broadway NC 27505
Application #: 17-5-42674 Subdivision: Lot #:
Type of Facility Served by Well: Existing Migrant House
Sewage System: Conventional
Permit Conditions:
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 Agen Date -7' 17
Grouting Inspection Wim ssed 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)
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 Agent
See Attachment for completion sketch
Date
Application #: 17-5-42674 Applicant Name: David Etheridge Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch