Well Authorization to Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 15-5-37737 Subdivision: Lot #:
Applicant Name: Jonathan Powell
Address: 1019 Valley Rd. Spring Lake, NC 28390
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 revocation , , /!
Authorized State Agent/ % � o� C Date
Grouting Inspection Witnessed Date
❑ Grouting self -certified by driller GW -1 provided? M Yes ❑
See attachment for construction sketch
Nfit
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: 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 #: 15-5-37737 Applicant Name: Jonathan Powell Subdivision: Lot #:
Well Construction Sketch
Existing
Well
Septic
Tank,
1 0
House
100 ft. \
Driveway rWcII
Well Completion Sketch