New Well Authorization To ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0692 03 6740 Parcel #: 04 0692 0028 01 Application #: 13 -5 -31431 Subdivision:
Applicant Name: A.L. Champion
Address: 88 Colby Ln Angier N.C. 27501
Type of Facility Served by Well: Apartments
Sewage System: 25% Red
Permit Conditions:
Lot #: TR1
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 Ag t Jx9 Date
Grouting Inspection Wit ssed Date
F-1 Grouting self - certified by driller GW -1 provided? F-1 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 #:13 -5 -31431
Well Construction Sketch
Applicant Name: A.L. Cham 'on
��t k
i� Z 5
Subdivision: Lot #: TRl
Well Completion Sketch