New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-36511R Subdivision: Lynn Godwin Lot #: 7
Applicant Name: Henry Hart
Address: PO Box 916 Erwin NC 28339
Type of Facility Served by Well: SFD
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 ALTERATIONcif the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Pe't to r oca
Authorized State Agent Date 1 S )f
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: _
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To
From To
From To
Date Drilled: Total Depth: _ Replacement Well? ❑ Yes ❑ No
Top of Casing is in. above surface. Yield: gpm at _ ft.
Amount
Casing
From _ To
Diameter: Material: _ Thickness:
From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
Inspector: On Hold Date: Release Date:
Remarks:
Well Head Information
Casing Height: _ (above finished grade) Access Port:
Well ID Tag: Pump ID Tag: Sampling Tap:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Date
Grout
From 0 To
Material: Method: _
From To
Material: Method:
From To
Material: Method:
Vent Stack:
Backflow Preventer:
Application #: Applicant Name: Henry Hart Subdivision: Lynn Godwin Lot #: 7
Well Construction Sketch
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Well Completion Sketch