Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0624-52-0451.000 Parcel #: 050624 0023 11 Application #: 18-5-44101 Subdivision: Lot #:
Applicant Name: Ralph Snence Harrin tg on II
Address: 2548 Cokesbury Road Fuquay-Varina NC, 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Location - 2395 Cokesbury Road Fuauav-Varina NC, 27526
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 ilO Date V (-L•7* f cion$
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 #:18-5-44101 Well Contractor:
Applicant Name: Ralph Spence Harrington II
Address: 2548 Cokesbury Road Fuauav-Varina NC, 27526
Directions to Site: 2395 Cokesbury Road Fuauav-Varina NC, 27526
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (deoth)
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
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:18-5-44101 Applicant Name: Ralph Spence Harrington II Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch