New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-37133 Subdivision: _ Lot #:
Applicant Name: Randall & Abigail Dolinger
Address: 1185 South River Rd. Lillington, NC 27546
Type of Facility Served by Well: SFD
Sewage System: pump to 25 % Reduction
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 re ation
Authorized State Age 6.� . 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
(death)
Casine
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:
Well ID Tag: _ Pump ID Tag: Sampling Tap: _
Sample Taken? ❑ Yes ❑ No Well Head properly sealed:
Remarks:
Authorized State
See Attachment for completion sketch
Vent Stack:
Backflow Preventer:
Application #: 15-5-37133 Applicant Name: Randall & Abigail Dolinger Subdivision: Lot #:
Well Construction Sketch
Area for
Well
Building
50 ft.
Water
(:hole/Pond
Home
Septic and -----*- ❑
pump tanks--� 1-1
Area for
Drain field
Well Completion Sketch