New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0615 94 4233.000 Parcel #: 05 0615 0001 25 Application #: 13 -5 -30947 Subdivision: Lot #:
5A
Applicant Name: Slade Dwayne Register
Address: 756 Oakridge Duncan Road F.V. N.C. 27526
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
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 LI- 11 -13
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
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #:13 -5 -30947 Applicant Name: Slade Dwayne Register Subdivision:
Well Construction Sketch
0
ari
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Lot #: 5A
15 6IV5
Well Completion Sketch