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Home My WebLink AboutWELL-03-2016-069712.TIF Case# r8 \ CATAwBA COUNTY WELL-03-2016-069712 ,Q e " �% Public Health Department Subdivision Mobile Home Estates � L /jiff) Environmental Health Division PINK 460604735886 tt PO Box 389, 100-A Southwest I31vd,Newton,NC 28658 LOT# 48 1842 sw NAME ON PERMIT: AARON DYKE, 7780 SKYLINE DR, SHERRILLS FORD NC 28673 Site Address: 7780 SKYLINE DR, SHERRILLS FORD NC 28673 Property Size: Square Feet:20,473.20 Acres:.470 Directions: NC Hwy 150, right Slanting Bridge, 1.5 miles right on Wildlife, left on Skyline Dr, 3rd house on right Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that I 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 perntit(s) as requested in the application for service EHPR-02-2016-23256 , 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: 03/03/2016 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 03/03/2016 08:34 Page 3 of 3 r avA CATAWBA COUNTY 0 • G 0 Case# WELL-03-2016-069712 ,� TiM®a Public Health Department T Y'. Subdivision Mobile Home Estates 1��31 y Fes . '• . Q -` (I* Environmental Health Division r -r PIN# 460604735886 -' PO Box 389, 100-A Southwest Blvd,Newton,NC 28658tor- O A LOT# 48 Ni842 •• t:-- 0 El I . 80 0 • NAME ON PERMIT: AARON DYKE, 7780 SKYLINE DR, SHERRILLS FORD NC 28673 Site Address: 7780 SKYLINE DR, SHERRILLS FORD NC 28673 Property Size: Square Feet: 20,473.20 Acres:.470 Directions: NC Hwy 150, right Slanting Bridge, 1.5 miles right on Wildlife, left on Skyline Dr, 3rd 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 timeframes 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 03/03/2016 AUTHORIZED STATE AGENT APPROVAL DATE ehpermit 03/03/2016 08:34 Page 1 of 3 �1\3`. Permit# EHPR-2-1 6-232 56 CATAWBA COUNTY �, C' Name Aaron Dyke F 'L Pnblic Health Department r3 Address 7780 Skyline Drive Shen-ills Ford < QA, Environmental Health Division � � PO Box 389, I OOA Southwest Blvd, Newton NC 28658 NC /8 41, s+ (828)465-8270 Fax (828)465-8276 TDD(828)465-8200 PIN# 460604735886 Site Plan Well Permit L 1 cLQ._ e :4- oo l5- c) 67 c f+ccc, (� a ( r lc ^r Lc cc gor ( 1Sl 5t—pi- Cc 45x0 4-'-i' ICLL -1,- n a 6Ln N l4,' 1)r N bj,,II I 9 ' 0 I0 I ( C.-14 -- 4-6.,:4 c/'- c �c3 W.--(1 I I YY bbb ,� /0 (\i,,„, W ( S S . y y , S lc / Y ".e. 0 r R J e.t bccltS I"'t‘' r V\. r �J- . L.V LI V r. I L r •I 1-, pp Spc- ail,_ ° 3(27/4 t _ se , 1 Scale DocuSign Envelope ID:E47DDB21-9143-4B19-B4E8-F6B8CE56EE4E NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS: PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300 WATER SUPPLY WELLS UNDER 15A NCAC 02C.0107 All water supply wells not considered"Private Drinking Water Wells"and including irrigation,industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible submittals will be returned as incomplete. 12/13/2023 DATE: , 20 PERMIT NO.: (to be completed by DWQIDPH) • A. WELL OWNER—For single family residences list the property owner(s). For all others, list name of the business, organization,or government agency and person delegated signature authority: Nicole Sherrill Timothy Furr Mailing Address: 401 Hawthorne Ln Ste 110-192 City: Charlotte State: NC Zip Code: 28204 County: Mecklenburg Day Tele No.: 7044081813 Cell No.: EMAIL Address: nsherri 118@gmai 1.com Fax No.: B. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number(PIN)of well site: County: CATAWBA (2) Physical Address(if different than mailing address): 7780 SKYLINE DR, ,rItKKiLLS-I-OKU • City: State:NC Zip Code: 28673 C. WELL DRILLER INFORMATION(if known) Well Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person: City: State: Zip Code: County: Day Tele No.: Cell No.: EMAIL Address: Fax No.: Fenn OW-22V Page 1 Revised February 2013 DocuSign Envelope ID:E47DDB21-9143-4B19-B4E8-F6B8CE56EE4E D. REASON FOR VARIANCE REQUEST — Include type of wells) to be constructed; rule for which the variance is .• being requested; description of how the alternate construction will not endanger human health and welfare and the environment;and reason why construction and/or operation in accordance with the standards is not technically feasible and/or provides equal or better protection of the groundwater. Requesting a variance for 15A NCAC 02C .0107(a)(2)(P). Requesting to construct a new deck 24 feet from an existing drilled well. E. ATTACHMENTS—Provide the following information as attachments to this application: (1) A map showing general location of the property (including road names, NC State Route Number, distances, any key landmarks,etc.)sufficient for finding the well location. (2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building foundations,property lines,water bodies,potential sources of contamination,other wells,etc. (3) Submit a copy of the local well permit application and site evaluation map(if applicable). (4) Any other information relevant to the variance request such as a well construction diagram showing proposed well liner or atypical construction materials/methods. F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional construction requirements beyond those specified in 1SA NCAC 02C .0107 be mct. Minimum additional construction requirements for Coastal Plain and Piedmont and Mountain region wells arc referenced on Attachments A and B on pages 4 and 5 of this application. Approval of a variance will not be considered in cases where the specified minimum additional construction requirements cannot be met. G. SIGNATURES �Docuslpned by: `-4EF2D3549F934D4... Signature of Person Responsible fur Well Construction(typically the well driller) Nicole sherrill Print or Type Full Name of Person Responsible for Well Construction (typically the well driller) (AA Signature of County/I Environmental� Health Specialist • /` / 0 L b r)il 1 �t1-11 p,r Print or Type Full Name of County Environmental Health Specialist Per 15A NCAC 02C.0118 the Secretary of the Division of Water Quality or the Division of Public Health may require submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as • described in G.S. 150B-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 North Carolina Please submit this form along with a Well Variance Application for an existing Department of Health and Human Services Division of Public Health private water supply well. Existing Well Variance Inspection Report Well Site Location: (Town,community,subdivision and Lot#) Address: 77 3° S 14 y bo. Pr County: C -i<aw 1,1, City/ST/Zip: j-A,rrt,'ll,r Pof a' NC 2 g6 7 3 Date of SiteVisit: l 7- 5-- 2 3 Well Construction Well Head Completion Date of Well Construction: 1— %— 2 oft Is the well head 12"above land surface?YES orab If unknown,was it drilled before 1972? YES or NO If no,what is the height of the casing: 8 inches If unknown,was it drilled before 7/1/2008?YES or NO Is there a sanitary well seal? kE3 or NO What type of well is it: Is the sanitary well seal in good repair?&E�'or NO IIIIIP Bored Hand Dug Jetted Other Are the following items present at the well head? Does the well have a cement slab? W or NO Vent n Sample Tap V 9 Well Tag 1p.r Pump Tag 1y,,t-s Does the well appear to be grouted? op or NO Potential Sources of Contamination? Does the well currently meet separation requirements with kr1rn sources of contamination? YES or / If no,please provide distances to those it does meet: `Z 1 -f-co wi a ru-4 1 ('0,i ':174 Other comments: Coiiiplete be/ow. )0°blu )0 ill( Name of person completing this form(please print): }'/r Catawba County Environmental Health ,LyN tO -yea° •778 '0 q4 135.15 118.74 rj ■ 'cam Parcel: 460604735886, 7780 SKYLINE DR lin=40ft SHERRILLS FORD, 28673 This map/report product was prepared from the Catawba County,NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling Information contained on this map or data on this report.Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2023 Catawba County NC 12/19/2023 k.. J• , M.. ..'t Ni1:• 1') 1 : Via. 1 •'..,144%•:31'‘-•.'- ,. ' �I ,,++ vek „•w�' _ i I'I-',S? „p,. yy,� y �.< iypi .i. x A �.VU: �. �: ... `,. - _ ter,, r 1/4 ' # -4 • N i \\\ • ?-. , Rai. `'� '.� 4- - - 11?''. _fix a'�'.`3 ,o- 4 w�. P a 4 . 4, ? I,, it 411,,...... ...,001t- ' Z '�84tv 7l� t q/��(j( r:r .P Fv rf �� NF m(t r It'" s+ • ''C ` 1 -4 fG Q x ' t '