Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #:9692-68-5568 & 9692-69-1179 Parcel#:
Applicant Name: Howard, Tim & Tara
Address: 7009 Carpenter Fire Station Rd Cary NC 27519
Type of Facility Served by Well: SFD
Sewage System: Conventional
Permit Conditions:
Application #:18-5-44325 Subdivision: Lot #:
General Permit Conditions:
• Drinking water supply well construction must meet 15A NCAC 02C.100 rules
• The permitted dffikmg water supply well shall be located in accordance with the SITE PLAN
• ANY ALTERATIO to of the site (including location of structures and appurtenance) or modification in use of the well, may
subject this Pegj>V revo
Authorized State Agent\
Grouting Inspection Witnessed
❑ Grouting self -certified by driller GW -1
See attachment for construction sketch
_ Date _
Yes ❑ No
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address: _
Directions to Site:
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)
From To
From To
From To
Inspector:
Remarks:
Casine
From To _
Diameter: Material: _ Thickness:
From To
Diameter: Material: Thickness:
From To
Diameter: Material: Thickness:
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
Grout
From 0 To _
Material: Method:
From To _
Material: Method:
From To
Material: Method:
Vent Stack:
Backflow Preventer:
Application #: 18-5-44325
Well Construction Sketch
Applicant Name: Howard, Tim & Tara Subdivision: Lot #:
Well Completion Sketch
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