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HomeMy WebLinkAboutWELL-02-2016-069430.TIF `�2,• ,• CATAWBA COUNTY Case# WELL-02-2016-069430 ,Q' ,I 2 Public Health Department Subdivision 1 < 1 N Environmental Health Division PIN# 379004741676 . PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOU/Ig sm, NAME ON PERMIT: DAVID JAROSZEWSKI, 147 KNOXVIEW LN, MOORESVILLE NC 28117 Site Address: 1258 BOLTON RD, CATAWBA NC 28609 Property Size: Square Feet:35,719.20 Acres:0.82 Directions: Hwy 16 South, Left onto Buffalo Shoals Rd, At Bandys Crossing, At stop sign Right onto Sherrills Ford Rd, Left onto Long Island Rd, Left onto Bolton Rd, 4th house on Right. Owner/Authorized Representative Acknowledgement of Permit Receipt 4 Q I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. :17:91_, As the property owner or authorized representative, I have received the above referenced permit(s) as . requested in the application for service EHPR-02-2016-23195 by the following method(s): ' , Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/ E-mail (Return receipt required) As the property owner or authorized representative I have reviewed and understand the specific conditions of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. Permit Issue Date: 02/23/2016 v ---)Owner/Authorized Representative Signatur )„Anil (hal Date orayn/ /'MI -h II / Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We want to hear from you. Please take a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EHCustomerService ehpermit 02/23/2016 09:05 Page 3 013 g• . CATAWBA COUNTY Case# WELL-02-2016-069430 Q• _�\ Public Health Department Subdivision L ® Q i 't ,� Environmental Health Division PIN# 379004741676 PO Box 389, 100-A Southwest Blvd,Newton. NC 28658 LOT# Ig¢2 su NAME ON PERMIT: DAVID JAROSZEWSKI, 147 KNOXVIEW LN, MOORESVILLE NC 28117 Site Address: 1258 BOLTON RD, CATAWBA NC 28609 Property Size: Square Feet:35,719.20 Acres:0.82 Directions: Hwy 16 South, Left onto Buffalo Shoals Rd, At Bandys Crossing, At stop sign Right onto Sherrills Ford Rd, Left onto Long Island Rd, Left onto Bolton Rd, 4th house on Right. Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that 1 am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in the application for service EHPR-02-2016-23195 by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/ E-mail (Return receipt required) As the property owner or authorized representative I have reviewed and understand the specific conditions of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. Permit Issue Date: 02/23/2016 Owner/Authorized Representative Signature Date Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We want to hear from you. Please take a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EHCustomerService ehpennit 02/23/2016 09:05 Page 3 of 3 y,A & CATAWBA COUNTY 0 T itib Q Case# WELL-02-2016-069430 C: §4®t% Public Health Department 4_ .M' Subdivision 2 q 4 Environmental Health Division � {1•r PIN# 379004741676 �4® �/ PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 , k j�• '+ LOT# Q rkkariAlt NAME ON PERMIT: DAVID JAROSZEWSKI, 147 KNOXVIEW LN, MOORESVILLE NC 28117 Site Address: 1258 BOLTON RD, CATAWBA NC 28609 Property Size: Square Feet:35,719.20 Acres:0.82 Directions: Hwy 16 South, Left onto Buffalo Shoals Rd, At Bandys Crossing, At stop sign Right onto Sherrills Ford Rd, Left onto Long Island Rd, Left onto Bolton Rd, 4th house on Right. WELL PERMIT WATER SUPPLY: Individual Well SETBACKS: 1. BUILDNG FOUNDATIONS 25 FT. 2 . EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT. 3 . EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 4 . SEWAGE PUMP SUPPLY LINE 50 FT. 5. UNDERGROUND STORAGE TANKS 100 FT. 6. STREAMS/BROOKS/CREEKS 50 FT. 7 . LAKES/PONDS RESERVOIRS 50 FT. ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT. The well driller must verify all setbacks before drilling the well. If the well driller is unable to maintain any of the above setbacks, contact Catawba County Environmental Health at (828) 465-8270 before drilling the well. Grouting Depth: Minimum 20 Feet Casing Height: 12" Above Land Surface All newly constructed private drinking water wells are required to be sampled in accordance with the North Carolina Rules Regarding Private drinking Water Well Testing (15A NCAC I 8A .3800). The fee for this sampling is included in the cost of the well permit. It is the applicant or property owner's responsibility to notify Environmental Health when the well is ready for sampling. Water samples will be drawn from an outside faucet unless otherwise specified. Please note that all water samples are taken during one visit. The processing laboratories have different protocols and timefrarnes for reporting results; therefore,you may receive several different reports concerning your water sample. For questions or more information, please contact Catawba County Environmental Health at(828)465-8270. Jason Boyd 02/23/2016 AUTHORIZED STATE AGENT APPROVAL DATE ehpennit 02/23/2016 09:05 Page 1 of 3 intik A Permit# EHPR-2-16-23195 CATAWBA COUNTY Nam e David Jaroszewski 2 Public Heal[h Department Q .3 Address 1258 Bolton Rd Catawba NC �" 9 Environmental Health Division PO Box 389, I00A Southwest Blvd, Newton NC 28658 PIN# 3 7900474 1 676 lg42 828)465-8270 Fax (828)465-8276 TDD(828)465-8200 , Site Plan Well Permit 6 o 11-04 I3 � oo L,' LS 0 cr..^ IIIIMMIIIIMMINNIIINSISNIMOIII It ` cx9 , . Ci Wctl Z 6 c (t-x '=-1- -- 6 71 e, 4-o r 7 i« f LI l__„_r------'5:-__-_________7 el-OU �/� A p oroX 0rc1hC.�l) Z6o .9 g' Z' C 3 11rL* s]- m'- f- W( I„,L /I dr;lltr 10° '¢ 1`) iL g s I I Q.,13 Chcol Tc a-C�,,y L/ l1 / /6 -ho lo C-c1- .p r\ % �ru r‘ / 37 Scale s 5 0 1 � RESIDENTIAL WELL CONSTRUCTION RECORD M to •nrth Carolina Department of Environment and Natural Resources•Divia;m of Water Qua'ir) • •••••• 1 WELL CONTRACTOR CERTIFICATION N 1.13.2.- 1,WELL CONTRACTOR:� ,,// n /( p. WATER ZONES td/e�p/r�•)n el. 7 /1"uM�I( Yep /Q Bohm A 46 Top Sodom Well Contra tar(Ird;vidue Na�me1��A 4 /� Too Bottom This Bottom Till Contra &k Jt t&LA4J Top Boron Top Bottom Wan Contretlor Company Name (f 2 1.., 1E/j ThIckneMar T. CASING: Depth Diameter Wotan Materiel S�:mat A�d//�7e�ta Too_a_.Botom 7E- pe (� _SRI 4.1 LLU4f�•fI.ULLUf1. St, .rand Top Bottom Ft. PdL City o(Town Sale Zip Code ToP�_Bottom Fl u t', /3i 7311 -- Area code Pnone number .9. GROUT, Depth Ma'efal ,Q Nletnoe 2.WELL INFORMATION: Top_a_Bottdn_RY) Ft , !%2irget, WELL CONSTRUCTION PERMITS O�'-2.O/b-Q6943O Top Bottom • et �/ 7 OTHER ASSOCIATED PERMIT�¢(od oppika:o) 0 00 Bottom FLf4.SIIAY't.ct/ Chip& SITE WELL 1041(e uoecatin .�s132 9. SCREEN: Depot Dlartstsr Slot Size Metortai ' 3.WELL USE(Check Apaicable Box;: Resaemita Water Suopiy 0 Top Sodom Ft. In _• in. DATE DRILLED 3 /4c Flo. T. Boaom. Ft. in. _ In. TIME COMPLETED .I. _ AND °M© Top Bottom FL in. M, a.WELL LOCATION: 10.SAND/GRAVEL PACK: �1,.. Depth Site Marla' CrTY etreeasitt_ '''COUCN'Y �.4et Top Worn Ft. /0(fie iitl rrt, ' C�(e/a6r( fader Top Bottom Ft (Sane:Na Namova oeamw'ry.S.tbSMvioa.Let No;eai.2ip Coat) Tao Bottom___FL TOPOGRAPHIC i LAND SETTING: (d o z enprop oie eon ❑9ope _Valley OFlat Ctane Other 11.DRILLING LOG .. ' Top Bottom Fonnadon Description LATITUDE • _ -DMS OR 3x.rocoo 00(DD 1 LONGITUDE ____•_ 'WAS OR Tx.xxxxxtootx OD 78 1 7O fit & Latlludefongitude source: BPS CTopoqrsorile map 1 re of well must be shown on 0 USGS tom map andeuaoheato ) 7a Fl I o �26(Trt ti-,a form it not using GPS) - 1 5.WFJ-L OWNER• j 09,442,m We, hn AK Zazani rthtk K(tu skf/• 1 Owner Name / 1 /4(7 a/Ok/Se4/ 4/.niD IIlc[sdi%/F 1 .Street Address . • - . . - / • Q/tr31/1//vt • d{C -,t7//1 t City or Town . State Zlo Code i ( / ) le4` 976` SSfn1 1 Area code Phone number 12, REMARKS: 6.WELL DETAILS:. a. TOTAL DEPTH: .2.65- b. DOES WELL REPLACE EXISTING WELL? YES® NO..71 ' DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top at Casing: 64 Fr. ACCORDANCE WTH 15A NCAC 2C,WELL CONSTRUCTION WOO' •if Above Too of Casing) STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEU.OWNER. d. TOP OF CASING IS / FT.ADOVO Land Starine• • Top of Casing terminated aVOr below land surlaoe may require flyyyn/i./9I /,� I /$' /6 a variance in ateareAnce with 15A NCAC 2C.0116. SIGNATURE OF CERTIFIED WELL CpCNTRACTOR DATE O. YIELD(gpm): a2 S METHOD OF TEST_A F ►3o.vn(d, rn�cv /fr7SSe f 1. DISINFECTION:Type .WH Amount / GtiO PRINTED NAME Oi= cotcmUCRNNGG THE WELL Sutt/Ike a diesitial tU ttte ORvisioft etWattfr owifityWithifk$0 days. Atal:.S rrrw94r gitit, Fam GW1.