Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0691-01-6254.000 Parcel #: 070691 0151 02 Application #: 17-5-42816 Subdivision: NA Lot #: NA
Applicant Name: SECU RE Inc. (Sam Adams)
Address: 119 N SALISBURY ST RALEIGH. NC 27603
Type of Facility Served by Well: SFD
tJoL�o toe. jyl,boc sLvled na t�).bor ��
Sewage System: Conventional Gravity -Feed Gravel .aeA6 ao— u t bra
Permit Conditions: Location - 44 HILLBILLY LN COATS, NC 27521
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 Agent Date 1 a ao i
Grouting Inspection Witnessed 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
See Attachment for completion sketch
Application #:17-5-42816
Well Construction Sketch
Well Completion Sketch
Applicant Name: SECU RE Inc. (Sam Adams)
5gpT%(..
(Lq-PA'1L- 110 t
rpt sT,�b
,�P�T�L ntnc�q
Subdivision:
1=X r M N \ leo i
1�\ t
wF.�l
P4.
-�" 111 L— uL LLtY 'L rJ
d Ind Hl"GtLLr L+-�
Lot #:
001 Shall f
kobte M1+13 Fr
Ceaf GO( -U.57 c
bqP >