Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1600-10-1163.000 Parcel #: 071600 011101 Application #: 18-543277 Subdivision:
Applicant Name: Christie Ross
Address: P.O. Box 995 Coats, NC 27521
Type of Facility Served by Well: Pole Barn
Sewage System: Conventional or 25% Reduction Svst
Permit Conditions: S LINCOLN ST
Lot #:
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
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -I provided? ❑ Yes El Wo
See attachment for construction sketch
Date: Application #:18-543277
Applicant Name: Christie Ross
Address: P.O. Box 995 Coats, NC 27521
Directions to Site: S LINCOLN ST
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
(deoth)
Casine
From _
To
From _
From _
To _
Diameter:
From _
To _
From
Diameter:
From
Diameter:
Inspector: _ On Hold Date:
Remarks:
Material: _ Thickness:
To
_ Material: _ Thickness:
To
_ Material: Thickness:
Release Date:
Grout
From 0 To _
Material: _ Method:
From To _
Material: _ Method:
From _ To _
Material: Method:
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
Date
Application #:18-5-43277 Applicant Name: Christie Ross Subdivision: Lot #:
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Well Completion Sketch
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