Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1507-49-5285.000 Parcel #: 021508 0038 Application #: 17-542935R Subdivision: NA Lot #: NA
Applicant Name: Jorge G. Hernandez
Address: 64 K.B. Lane Angier, NC 27501
Type of Facility Served by Well: 4 Bedroom 70ftx28ft DWMH
Sewage System: 25% Reduction System
Permit Conditions: 219 Edna John Ct. (Suggs Rd. - SR 1727)
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 /aol P
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
See Attachment for completion sketch
Application #:17-5-42935R Applicant Name: Jorge G. Hernandez Subdivision: NA Lot #: NA
Well Construction Sketch
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Well Completion Sketch