Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0654-70-8511.000 Parcel #: 080653 0108 Application #: 18-543967 Subdivision:
Applicant Name: Randy & Ramona Byrd
Address: 6600 Walnut Cove Drive Raleigh, NC 27603
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Shady Brook Lane (Lafayette Road - SR 1443)
Lot #: 1
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
Date: Application #:18-5-43967
WELL CERTIFICATE OF COMPLETION
Well Contractor:
Applicant Name: Randy & Ramona Byrd
Address: 6600 Walnut Cove Drive Raleigh, NC 27603
Directions to Site: Shady Brook Lane (Lafayette Road - SR 1443)
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: 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 #:18-5-43967
Well Construction Sketch
Applicant Name: Randy & Ramona Byrd Subdivision: Lot #: I
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