Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1518-77-1077.000 Parcel #: 021517 0405 01 Application #: 17-5-42650 Subdivision:
Applicant Name: James Jackson: Lone N. McLean
Address: 436 Oak Valley Farm Road Coats, NC 27521
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Brookleaf Drive (Fairground Rd. - SR 1705)
Lot #: 1 B
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 Witnes
❑ Grouting self -certified by
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 #:17-5-42650 Applicant Name: James Jackson Subdivision: _ Lot #: 1B
Well Construction Sketch
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Well Completion Sketch