New Well Authorization to ConstructPIN #: 1610-87-9473.000 Parcel#:
Applicant Name: Martin H Yde
Address:
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction
Permit Conditions:
HARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
Application #: 15-5-35299RR Subdivision: Lot #:
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 Aggaf � � / �,L 1Ltne3 Date /Z /la i S
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)
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: 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
Date
Application #:15-5-35299RR Applicant Name: Martin H Yde Subdivision: Lot #:
Well Construction Sketch
Well Completion Sketch