New Well Authorization To ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: 1507-38-6761 Parcel #: 1507-38-6761.006
Applicant Name: Melvin Stewart &Brenda Mcneil
Address: 1451Red Hill Church RD Dunn N.C. 28334
Type of Facility Served by Well: DWMH
Sewage System: 25% Reduction
Permit Conditions:
Application #: 15-5-3691OR Subdivision: Walts Crossing Lot #: 7
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 A en LI/��/sem 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)
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
See Attachment for completion sketch
Application #:15-5-3691 OR Applicant Name: Melvin Stewart & Brenda Mcneil Subdivision: Walts Crossing Lot #: 7
Won ('nnetrnrtinn Ckotrh
Well Completion Sketch