Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0598-88-8901.000 Parcel #: 071508 0046 04 Application #:17-542686 Subdivision: Fred Turlington
Applicant Name: Mark Craft (Greenfield Housing)
Address: 2117 Hwy70 East Gamer NC 27529
Type of Facility Served by Well: Single Family Modular
Sewage System: Accepted System
Permit Conditions:
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 ALTE of the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Perm(1 to rem tie*,
Authorized State Ag Date %1) 1-2 1
/r —iz—/-20-
Grouting Inspection Witiressed 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? F-1Yes
El 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:
Vent Stack:
Well ID Tag: _
Pump ID Tag: _
Sampling Tap:
_
Backflow Preventer:
Sample Taken? ❑ Yes
❑ No Well Head properly sealed:
_
Remarks:
Authorized State
See Attachment for completion sketch
Date
Application #: Applicant Name: Subdivision: Lot #:
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Well Completion Sketch
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