Auhorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0545-58-3059.000 Parcel #: 12 0545 0035
Applicant Name:Nathaniel Torberson
Address: 4601 Blanton Rd Fayetteville, NC 28303
Type of Facility Served by Well: SFD
Sewage System: Pump to 25% Reduction
Permit Conditions:
Application #: 18-5-43460 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 ALTERAT f the site of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Penritjo rev
Authorized State Agent DateAWIA—
Grouting Inspection Witnessed_ Date
❑ Grouting self -certified by driller GW -I 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? ElYes ❑ No
Static Water Level: Top of Casing is _ in. above surface. Yield: _ gpm at _ ft.
Disinfection: Type _ Amount
Water Zone
(depth)
Casing
From
To
From
To
Grout
_
From _
_
To _
_
Diameter:
_ Material: _
Thickness:—
From 0 To _
Material:
From _
To _
From _
To _
_Method: _
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 #: 18-5-43460
Well Construction Sketch
Well Completion Sketch
Applicant Name: Nathaniel Torberson Subdivision: _ Lot #:
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