New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-37326 Subdivision: Lot #: 6
Applicant Name: Jennifer L Morton
Address: 139 Ned Lane Swansboro N.C.
Type of Facility Served by Well: SFD
Sewage System: 25%Reduction System
Permit Conditions:
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 ent Date -2'v t S`
Grouting Inspection Witressed 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:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method: _
From To _
Thickness: Material: Method:
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 #:15-5-37326 � Applicant Name: Jennifer L Morton Subdivision: Lot #: 6
Well Construction Sketch
Well Completion Sketch