Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9598-747276 000 Parcel #: 039598 0008 07 Application #: 17-5-42998 Subdivision: Curtis Hair Est. #17-23213
Applicant Name: Ricahrd Wilkes
Address: 1451 Overhills Rd. Linden, NC 28356
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Buie Road (NCSR 1213)
Lot #: 4
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 Ato '�/
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 Agent Date
See Attachment for completion sketch
Application #:17-5-42998
Well Construction Sketch
Well Completion Sketch
Applicant Name: Ricahrd Wilkes Subdivision: Curtis Hair Est. #17-23213 Lot #: 4
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