Authorization To Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1528-64-2716.000 Parcel #: 021526 0470 Application #: 17-542671 Subdivision: Lot #: Par #1
Applicant Name: Ken Dawson Homes, Inc
Address: 120 Edmondson Drive Willow Springs, NC 27592
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - Bryan McLamb Lane (US 301 N.)
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 Wtfnessed
❑ Grouting self -certified by driller GW -1 provided?
See attachment for construction sketch
Date _
Yes F] No
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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:
glint at ft.
Disinfection:
Type _
Amount
Water Zone
(death)
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 Date
See Attachment for completion sketch
Application #:17-5-42671 Applicant Name: Ken Dawson Homes, Inc Subdivision: Lot #: Par #1
Well Construction Sketch
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Well Completion Sketch