HomeMy WebLinkAboutNew Well Authorization to Construct Permit RHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0643 -47 -1169 Parcel #: 08- 0643 - 0010 -01
Applicant Name: Bill Swa} ney_
Address: Deer Tail Lane F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25%
Permit Conditions:
Application #: 13- 5- 30756r Subdivision: Lot #: 2A
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 Age -,✓ Date - ►-( -( Y
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 #: 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)
Casing
From
To
From
From
To
Diameter:
From
To
From _
Diameter:
From _
Diameter:
Inspector: On Hold Date:
Remarks
Grout
To From 0 To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
To From To
Material: Thickness: Material: Method:
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 Agent
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #:13- 5- 30756R Applicant Name: Bill Swayney Subdivision: Lot #: 2A
Well Construction Sketch
Well Completion Sketch