Authorization to construct new wellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #:0536-48-4429.000 Parcel #: 010536 0044 03 Application #:17-5-42823 Subdivision:
Applicant Name: Philip David Webb
Address: 553 Farrar Dairy Rd Lillington NC 27546
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions:
Lot #:
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 Pec.�t to revq ' n
Authorized State
Grouting Inspection Witnes
❑ Grouting self -certified by
See attachment for construction sketch
Date )�- 1
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)
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
Application #: Applicant Name: Subdivision: Lot #:
A -31'-R Opm�v V 68!)
Well Construction Sketch
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W ELS+ I
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Well Completion Sketch