Well Authorization to Construct PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #:15-5-36406
Applicant Name: Percy Truelove
Address: 893 Truelove Rd. Holly Springs, NC 27540
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
Subdivision: Lot #:
Permit Conditions: Well to be drilled in Well Area: WELL CONTRACTOR TO MEET ONSITE PRIOR TO DRILL WELL
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/!L- Date 7 12, 2-t-r—
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
Grout
From To
From 0 To
Diameter: Material: Thickness:
Material: Method:
From To
From To
Diameter: Material: Thickness:
Material: Method:
From To
From To
Diameter: Material: Thickness:
Material: Method:
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 Date
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #:15-5-36406
Well Construction Sketch
Septic Drain
Field and
Repair Area
Applicant Name: Percy Truelove Subdivision: Lot #:
11 1......._ Home..._
Septic
Tank
Property
line
Well Completion Sketch
100 ft.
Well Area
I
60 ft.