Authorization to Construct New WellBARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1600-26-8872.000 Parcel #: 071600 0217 01 Application #: 18-5-43337 Subdivision: Lot #:
Applicant Name: Jeremy M. Strickland
Address: 1330 Lane Road Dunn, NC 28334
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location: NC 27 East - Well dependent on final location of septic - Contact health department
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 Agent %%) Date d S 116 /aa8
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: 03/15/2018 Application #:18-5-43337
Applicant Name: Jeremy M. Strickland
Address: 1330 Lane Road Dunn, NC 28334
Directions to Site:
Use of Well: Date Drilled: _
Static Water Level: Top of Casing is
Disinfection: Type Amount
Well Contractor:
Total Depth: _ Replacement Well? ❑ Yes ❑ No
in. above surface. Yield: gpm at _ ft.
Water Zone
(depth)
Casine
From _
To
From
To
From _
To
Diameter:
Material: Thickness:
From _
To
From _
To
Diameter:
_ Material: Thickness: _
From _
To _
Diameter:
Material: Thickness:
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
Grout
From 0 To
Material: Method:
From _ To
Material: _ Method: _
From To _
Material: Method:
Vent Stack:
Backflow Preventer:
Application #:18-543337
Well Construction Sketch
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Well Completion Sketch
Applicant Name: Jeremy M. Strickland Subdivision: Lot #:
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