New Well ConstructionHARNETT DEPARTMENT OF PUBLIC HEALTH PERMIT
TO CONSTRUCT A DRINKING WATER SUPPLY WELL
PIN 0692-29-4529-000 Parcel 04-0692-0150 Application 11-5-26954 Subdivision:
Applicant Name: John & Karen Mertz
Address: 4340 Old Stage RD N Angier, N.C. 27501
Type of Facility Served by Well: SFD
Sewage System: Conventional
Permit Conditions: See site sketch
Lot
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 Ag nt Date t; - Z7 J f
Grouting Inspection Wi ` essed 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 #:11-5-26954 Applicant Name: John & Karen Mertz Subdivision: Lot
Well Construction Sketch
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Well Completion Sketch