New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0672 -13 -0713 Parcel #: 04 0672 0004 02 Application #: 11- 5- 27536R Subdivision: SMB
Applicant Name: Michael Chisek
Address: 367 Sherman Lakes Dr
Type of Facility Served by Well: SFD
Sewage System: Manitee to 25% Reduction
Permit Conditions:
Lot #: 2
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
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Authorized State Age Date -I ` 4.3
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)
From To
From To
From To
Inspector:
Remarks:
Casing
From To
Diameter: Material.
From To
Diameter: Material:
From To
Diameter: Material:
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:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Authorized State Agent Date
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:11- 5- 27536R Applicant Name: Michael Chisek Subdivision: SMB Lot #: 2
Well Construction Sketch
4J
Well Completion Sketch