New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN #:1538-13-6582.000 Parcel 02-1538-9000-08
Lot
Applicant Name: Kurt Stabler
Address: 3066 Fairground Rd Dunn N.C. 28334
Type of Facility Served by Well: SFD
Sewage System:25% Reduction System
Permit Conditions:
Application #:11-5-26198
Subdivision:
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 A nt Date 3-16-11
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
Inspector:
Remarks
Casing
From To
Diameter: Material:
From To
Diameter: Material:
From To
Diameter: Material:
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 Agent
Grout
From 0 To
Thickness: Material: Method:
From To
Thickness: Material: Method:
From To
Thickness: Material: Method:
Vent Stack:
Backflow Preventer:
Date
See Attachment for completion sketch
Application Applicant Name: Subdivision: Lot
Well Construction Sketch
Well Completion Sketch
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