Well Authorization to Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-36761 Subdivision: Lot #:
Applicant Name: S. Wayne Harrington
Address: 1183 Blanch Johnson Rd. Broadway, NC 27505
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled in Well Area
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�revation
State Agent �y-�o�_ Date �—,4(wi-
Authorized
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 Agent
See Attachment for completion sketch
Date
Vent Stack:
Backflow Preventer:
Application #: 15-5-36761 Applicant Name: S. Wayne Harrington Subdivision: Lot #:
Well Construction Sketch
House
H
A
R
R
I
N
New Well G
Area 0 T
O
Ei sting N
R
well D
Blanch Johnson Rd.
Well Completion Sketch