Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0680-52-0745.000 Parcel #: 070680 0024 Application #: 17-5-42839 Subdivision: Lot #:
Applicant Name: Richard Stafford
Address: 9230 Eagle Cove Circle, South Chesterfield VA 23803
Type of Facility Served by Well: SFD
Sewage System: ExistingSeptic
eotic
Permit Conditions: 1614 McLamb Road (SR 2003)
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 + �f� Date "TL-?2/'Fqe
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 #:17-5-42839 Well Contractor:
Applicant Name: Richard Stafford
Address: 9230 Eagle Cove Circle, South Chesterfield VA 23803
Directions to Site: 1614 McLamb Road (SR 2003)
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From _ To
From _ To
From To
Inspector:
Remarks:
Date Drilled:
Total Depth:
_ Replacement Well? ❑ Yes
❑ No
Top of Casing is
in. above
surface. Yield:
_ gpm at _ ft.
Amount
Casing
Grout
From _ To
From 0 To
Diameter: _
Material: _
Thickness:
Material:
_ Method:
From To
From
To _
Diameter:
Material:
Thickness:
Material:
Method:
From To
_
From
To _
Diameter:
Material:
Thickness:
Material:
Method:
On Hold Date:
Release Date:
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 Agent Date
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:17-5-42839 Applicant Name: Richard Stafford Subdivision: _ Lot #:
Well Construction Sketch
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Well Completion Sketch
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