Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0611-98-7673.000 Parcel#: 130611 0013
Applicant Name: Adam Rich
Address: 7562 Decator Drive Fayetteville, NC 28376
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Cummings Road (SR 1263,)
Application #: 18-5-43297 Subdivision: 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 A"flc-4---Z>
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Authorized State Agent Date
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 #:18-5-43297 Well Contractor:
Applicant Name: Adam Rich
Address: 7562 Decator Drive Fayetteville NC 28376
Directions to Site: Cummings Road (SR 1263)
Use of Well: _ Date Drilled: _ Total Depth: _ Replacement Well? ElYes ElNo
Static Water Level: _ Top of Casing is _ in. above surface. Yield: _ gpm at
Disinfection: Type _ Amount
Water Zone
(depth)
Casing
From
To
From
From _
To _
Diameter:
From _
To _
From _
Diameter:
From
Diameter:
Inspector: _ On Hold Date:
Remarks:
IV
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 #:18-5-43297
Well Construction Sketch
Well Completion Sketch
Applicant Name: Adam Rich Subdivision: Lot #:
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