New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0692-10-2364.000 Parcel #: 070692 0121 Application #: 18-544046 Subdivision: _ Lot #:
Applicant Name: Jonathan Wall
Address: 1269 Turner Meadow Drive Raleigh, NC 27603
Type of Facility Served by Well: SFD
Sewage System: Conventional or 25% Reduction Sys.
Permit Conditions: 100 Foot Septic Setback
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 c-'6%G'aGYe,
Grouting Inspection Witnessed Date _
❑ Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ No
See attachment for construction sketch
Date: Application #:18-5-44046
WELL CERTIFICATE OF COMPLETION
Well Contractor:
Applicant Name: Jonathan Wall
Address: 1269 Turner Meadow Drive Raleigh, NC 27603
Directions to Site: Between 3020 and 3100 Old Stage Road N (SR 1006)
Use of Well:
Date Drilled:
Total Depth:
Replacement Well? ❑ Yes
❑ No
Static Water
Level:
Top of Casing is
in. above
surface. Yield:
_ gpm at ft.
Disinfection:
Type
Amount
Water Zone
(depth)
Casing
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:
Application #:18-5-44046 Applicant Name: Jonathan Wall Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch 7
7