New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0692-67-0515.000 Parcel Application 11-5-27794 Subdivision: Lot
Applicant Name: Srinivasa Badarinarayana
Address: 341 Melvin Jackson Dr. Cary, NC 27511
Type of Facility Served by Well: SFD
Sewage System: pump to 25% reduction system
Permit Conditions: Well to be 100 ft. from any part of septic system
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 f!/ 7/;ZGl(
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
To
From
To
Diameter:
Material:
From
To
From
To
Diameter:
Material:
From
To
Diameter:
Material:
Inspector:
On Hold Date:
Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Remarks
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:
Vent Stack:
Backflow Preventer:
Remarks
Authorized State Agent
Date
See Attachment for completion sketch
Application #:11-5-27794
Well Construction Sketch
Applicant Name: Srinivasa Badarinarayana Subdivision: Lot
Well Area
100 ft.
House B
Initial Septic System
& Repair Area
D-- House A
Well Completion Sketch