Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1527-43-3665.000 Parcel #: 021527 0108 12 Application #: 18-543227 Subdivision: _ Lot #:
Applicant Name: Jerry Pounds
Address: 333 Josie Drive Benson, NC 27504
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - 156 Maude Parker Lane (Lane Road - SR 1802)
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 Ageu _ Date aslab//g
Grouting Inspection Witnessed Date _
El Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
Date: Application #:18-5-43227
WELL CERTIFICATE OF COMPLETION
Well Contractor:
Applicant Name: Jerry Pounds
Address: 333 Josie Drive Benson, NC 27504
Directions to Site: 156 Maude Parker Lane (Lane Road - SR 1802)
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 #:18-5-43227 Applicant Name: Jerry Pounds Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch