New Well Authorization to Construction PermitHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #:9568-48-2498.000 Application #:15-5-37259 Subdivision: _ Lot #:
Applicant Name: Joshua & Jennifer Goldberg
Address: 5948 Ponderosa Rd. Sanford, NC 27332
Type of Facility Served by Well: SFD
Sewage System: 25% Reduction System
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
c
Authorized State Agenti .._ , Date t- 2 o / Co
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)
From To
From To
From _ To
Casine
From To
Diameter: _ Material: _ Thickness:
From _ To
Diameter: Material: _ Thickness:
From To _
Diameter: Material: Thickness:
Inspector: _ On Hold Date:
Remarks:
Release Date:
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
Date
Grout
From 0 To _
Material: _ Method:
From To
Material: _ Method:
From To _
Material: Method:
Vent Stack:
Backflow Preventer:
Application #: 15-5-37259
Well Construction Sketch
Well Completion Sketch
Applicant Name: Joshua & Jennifer Goldberg Subdivision: Lot #:
To Thomas
Bailey Rd.
Septic Area — 100 ft.
Home — 232 ft.
100 ft.
Repair
Area —
Well Area