Authorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1518-87-7376.000 Parcel #: 021518 0140
Applicant Name: Jennifer Thoresen
Address: 520 Zachary Way Gamer, NC 27529
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Permit Conditions: Site - 118 Hobson Road (SR 1712)
Application #: 18-544110 Subdivision: 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 Agent Date 0*J(x'/o0$
Grouting Inspection Witnessed Date
F-1Grouting self -certified by driller GW -1 provided? ❑ Yes ❑ N_o
See attachment for construction sketch
WELL CERTIFICATE OF COMPLETION
Date: Application #:18-5-44110
Applicant Name: Jennifer Thoresen
Address: 520 Zachary Way Gamer, NC 27529
Directions to Site: 118 Hobson Road (SR 1712)
Use of Well:
Static Water Level:
Disinfection: Type
Water Zone (depth)
From To
From To
From _ To _
Inspector:
Remarks:
Well Contractor:
Date Drilled: Total Depth: _ Replacement Well? E]Yes E]No
Top of Casing is _ in. above surface. Yield: gpm at ft.
Amount
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 #:18-5-44110
Well Construction Sketch
Well Completion Sketch
Applicant Name: Jennifer Thoresen
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Subdivision:
_,
Lot #: 1
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