Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0653-89-8738.000 Parcel #: 080653 0108 02 Application #: 18-5-43344R Subdivision:
Applicant Name: HMT Construction LLC
Address: 228 George Wilton Dr. Clayton, NC 27570
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: 391 Shady Brook Lane (Lafayette Rd. SR 1443)
Lot #: 2
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
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -1 provided? E] Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #:18-5-43344R Well Contractor:
Applicant Name: HMT Construction LLC
Address: 228 George Wilton Dr. Clayton, NC 27570
Directions to Site: 391 Shady Brook Lane (Lafayette Rd. SR 1443)
Use of Well: Date Drilled: -Total Depth: _ Replacement Well? E]Yes [—]No
Static Water Level: _ Top of Casing is in. above surface. Yield: _ gpm at _ ft.
Disinfection: Type Amount
Water Zone
(death)
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 #:18-5-43344R
Well Construction Sketch
Applicant Name: HMT Construction LLC Subdivision: Lot #: Z
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Well Completion Sketch