New Well Authorization to Construct PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 0674 -34- 2326.000 Parcel #: 040674 002101 Application #: 13 -5 -31908 Subdivision:
Applicant Name: Bobby Joe Elkins
Address: 773 Rawls Church RD Anizier N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: County Sewer
Permit Conditions:
Lot #: 1
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 Agen �� Date Li-11 --t y
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
Grout
From
To
From
To
From 0 To
From
To
Diameter:
Material: Thickness:
Material: Method:
From
To
From
To
From To
Diameter:
Material: Thickness:
Material: Method:
From
To
From To
Diameter:
Material: Thickness:
Material: Method:
Inspector:
On Hold Date:
Release Date:
Remarks:
Well Head Information
Casing Height: (above finished grade) Access Port: Vent Stack:
Well ID Tag: Pump ID Tag: Sampling Tap: Backflow Preventer:
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State Agent Date
See Attachment for completion sketch
Application #:13 -5 -31908 Applicant Name: Bobby Joe Elkins Subdivision: Lot #: 1
Well Construe
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Well Completion Sketch
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