Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0663-90-8150.000 Parcel #: 040673 0121 12 Application #: 18-5-43039 Subdivision: Adams Farm Lot #: 313
Applicant Name: Karen Wood & Robin C000er
Address: 1000 Tyler Farms Drive Raleieh, NC 27603
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions: Millwood Lane (Hwy 201 N.) - Adams Farm SID Lot 3B
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 AgentL!/i% ��'" Date a at' oci I 1 ¢
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -I provided? E] Yes ❑ No
See attachment for construction sketch
Date: Application #:18-5-43039
Applicant Name:
Address: _
Directions to Site:
WELL CERTIFICATE OF COMPLETION
Well Contractor:
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
See Attachment for completion sketch
Application #:18-543039 Applicant Name: Karen Wood & Robin Cooper Subdivision: Adams Farm Lot #: 3B
Well Construction Sketch
Well Completion Sketch
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Well Completion Sketch