New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 1518-97-0694.000 Parcel 02-1518-0140-08 Application 11-5-26417R Subdivision: ROY DUNN
Lot 2
Applicant Name: James and Jerryline Alston
Address: 146 Hobson Rd Dunn N.C. 28334
Type of Facility Served by Well: M/H
Sewage System: 25%Reduction System
Permit Conditions:
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 1&~ gC?~?~~
Date ej ° I
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
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 Applicant Name: A 45C) Subdivision: 1 1*5 10 Lot
Well Construction Sketch
d i
s.
Well Completion Sketch