Authorization to construct New Welly HARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
DbDX50 TO CONSTRUCT A DRINKING WATER SUPPLY WELL
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PIN #: Parcel #: Application #: _ Subdivision: Lot #:
Applicant Name: -4).6
Address: --!SD
�n-moi IV•G 27�/G7
Type of Facility Served by Well: SFD
Sewage System: COIA-O'ex-i
Permit Conditions:
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 en Date
Grouting Inspection itnessed 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? E] Yes
E] No
Static Water Level:
_ Top of Casing is
in. above
surface. Yield:
_ gpm at ft.
Disinfection:
Type _
Amount
Water Zone
(deoth)
Casine
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:
Well ID Tag: _ Pump ID Tag: _ Sampling Tap: _
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
iv-. — -Ulf V_-_,
Application #:
Well Completion Sketch
v.—
Applicant Nam
Subdivision:
Lot M