HomeMy WebLinkAboutAuthorization to Construct New WellHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1527-29-9017.000 Parcel #: 021515 0403 Application #: 17-5-41216 Subdivision: NA Lot #: NA
Applicant Name: Gary Peacock
Address: 3069 US 301 N. Dunn, NC 28335
Type of Facility Served by Well: SWMH
Sewage System: 25% Reduction System
Permit Conditions: None
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 'ncluding location of structures and appurtenance) or modification in use of the well, may
subject this Permit to revocation
Authorized State A tf Date
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:
_ glint at ft.
Disinfection:
Type
Amount
Water Zone
(depth)
Casine
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
Application #:17-5-41216
Well Construction Sketch
Applicant Name: Gary Peacock Subdivision: NA Lot #: NA
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