New Well Authorization to ConstructHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #: Parcel #: Application #: 11 -5 -25990
Applicant Name: Norman Levon Cameron
Address: P.O. Box 336 Broadway, NC 27505
Type of Facility Served by Well: SFD
Sewage System: conventional
Permit Conditions: Well to be drilled above natural drain
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 I
Authorized State Agent � t, , zt I �r Date P
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:
Subdivision: Lot #:
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
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Inspector:
Remarks
On Hold Date: 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
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application #:11 -5 -25990
Well Construction Sketch
Applicant Name: Norman Cameron Subdivision: Lot #:
Well Area
0
0
a
n
R
d
Existing
Barn
Natural Drain
Septic System Area &
Home Repair
Old US 421
Well Completion Sketch