Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:17-5-42685 Subdivision: Fred Turlineton Lot #:6
Applicant Name: Greenfield Housing
Address: 2117 Hwy70E Gamer NC 27529
Type of Facility Served by Well: Modular (76'x30')
Sewage System:25% Reduction System
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 StateA nt _- ff� Date
fXC--1f15 1-7
Grouting Inspection Wi ,sed Date
❑ Grouting self -certified by driller GW -I 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)
From To
From To
From _ To
Inspector:
Remarks:
Casine
From To
Diameter: _ Material: _ Thickness:
From _ To
Diameter: Material: _ Thickness:
From To
Diameter: Material: Thickness:
On Hold Date: Release Date:
Well Head Information
Casing Height: _ (above finished grade) Access Port:
Well ID Tag: Pump ID Tag: _ Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head property sealed:
Remarks:
Authorized State Agent
See Attachment for completion sketch
Grout
From 0 To _
Material: _ Method:
From To
Material: Method:
From To
Material: Method:
Vent Stack: _
Backflow Preventer:
Application #:17-5-42685
Well Construction Sketch
Well Completion Sketch
Applicant Name:Greenfield Housing Subdivision: Fred Turlineton Lot #: 6
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