Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #:0517-34-4110.000 Parcel #:01236.0028.20
Applicant Name: Barbara Sanders
Address: 192 Mount Vista Dr. Lillington NC 27546
Type of Facility Served by Well: SFD
Sewage System: Conventional
Permit Conditions:
Application #: Subdivision: Little River Plantation Lot #:103
General Permit Conditions:
• Drinking water supply well construction must meet 15A NCAC 02C.100 rules
• The permittdrinking water supply well shall be located in accordance with the SITE PLAN
• ANY ALTERATION—Q1 the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Pem*Qo r&K-atioa
Authorized State
Date ga I1
Grouting Inspection Witnessed N Date _
❑ Grouting self -certified by driller GW -I provided? ❑ Yes r-1No
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
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 #: Applicant Name: Barbara Sanders Subdivision: Little River Plantation Lot #: 103
Well Construction Sketch
W OOp bb
JI
Well Completion Sketch