Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0596-27-3392.000 Parcel #: 060596 0258 29 Application #: 18-5-43959
Applicant Name: Lammoth O'Neal
Address: 7650 Snume Dr. Fayetteville, NC 28311
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction Sys. or Conventional
Permit Conditions:
Subdivision: River Bluff Rd. N Lot #: 2&3
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? ❑ Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #:18-543959
Applicant Name: Lammoth ONeal
Address: 7650 Spurp_e Dr. Fayetteville, NC 28311
Directions to Site:
Well Contractor:
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)
Casin¢
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:
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
Date
Application #:18-5-43959
Well Construction Sketch
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Well Completion Sketch
Applicant Name: Lammoth O'Neal Subdivision: River Bluff Rd. N Lot #: 2&3
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