Well CompletionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CO rRUCT A DRINKING WATER SUPPLY LL
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IN #: $36o Parcel #: 0 L Application#��t3^Ll Subdivision: Lot #:
Applicant Name: JAa �dN
Address: QI _� X-q-1o0�rZ AJ. C.
Type of Facility Served by Well: SFD
Sewage System: S,16 IZEib(7ZQ1,
Permit Conditions:
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 A h-*- r Date �b L
Grouting Inspection Wr eased %&A45 Date
❑ Grouting self -certified by driller W-1 provide �O Yes ❑ No
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #: Well Contractor:
Applicant Name:
Address: _
Directions to Site:
Use of Well: _
Static WaterI,evel:
Disinfection: Type
Water Zone (depth)
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
From To _
Diameter: Material:
From To _
Diameter: Material:
From _ To
Diameter: Material:
On Hold Date: Release Date:
Grout
From 0 To
Thickness: Material: Method: _
From To _
Thickness: Material: Method:
From _ To
Thickness: Material: Method:
Well Head Information
Casing Height: i 1 1 (above finished grad) Access Port: Vent Stack: _
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken?�Yes ❑ No Well Head properly seahl:
Remarks:
Authorized State
See Attachment for completion sketch
Date i a
/(0'S 39821 J Ack—
URydu.
Application #: Applicant Name: Subdivision: Lot #:
Well Construction Sketch
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Well Completion Sketch
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