New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 1506-23-8605.000 Parcel 061506 0005 05 Application 11-5-26139
Hamilton Est Lot 6
Applicant Name: John E Smith Jr
Address: 1220 Old Hamilton Rd Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System: 25%Reduction System
Permit Conditions:
Subdivision: Carl
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 Age 4?jlr-7~ c _ Date_
Grouting Inspection Witnessed Date _
F-1 Grouting self-certified by driller GW-1 provided? E] Yes F-1 No
3? ---7 - t r
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
Inspector:
Casing
From _
Diameter:
From _
Diameter:
From _
Diameter:
On Hold Date:
To
_ Material: _
To
_ Material: _
To
Material:
Release Date:
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
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
Date
Vent Stack:
Backflow Preventer:
See Attachment for completion sketch
Application #:11-5-26139 Applicant Name: John E Smith Jr Subdivision: Carl Hamilton Est Lot 6
Well Construction Sketch
Well Completion Sketch