New Well Authorization To ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 9553 -86- 9929.000 Parcel #: 099553 0017 02 Application #: 11 -5 -26286 Subdivision: Lot #: 4
Applicant Name: Red Door Homes
Address: 4002 Fayetteville Rd. Raeford, NC 28376
Type of Facility Served by Well: SFD
Sewage System: 25 % Reduction
Permit Conditions: Well to be drilled in Well Area and not under power line
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
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:
Authorized State Agent
See Attachment for completion sketch
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Date
Vent Stack:
Backflow Preventer:
Application #:11 -5 -26286 Applicant Name: Red Door Homes Subdivision: Lot #: 4
Well Construction Sketch
Power line �
Area for
iDrain
field
To Hillman
Barn
Grove Rd
Home
10
ft.
1
Well Area
path
Well Completion Sketch