Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #:0537-03-1079.000 Parcel#: 0105370009
Applicant Name: Mark Farnsworth
Address: 2782 Norrington Rd Lillington, NC 27546
Type of Facility Served by Well: Manufactured Home
Sewage System: Conventional
Permit Conditions:
Application #: 18-5-43279 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 ALTERAT40,N of the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Permit to r v
Authorized State Agent 1°. Date '316-6
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 #: 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 _ ft.
Disinfection: Type _ Amount
Water Zone
(depth)
Casing
Grout
From
To
From
To
From 0 To
_
From
To
Diameter:
Material: _
Thickness:
Material:
Method: _
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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 #: 18-5-43279 Applicant Name: Mark Farnsworth Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch
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Well Completion Sketch