HomeMy WebLinkAboutWELL-03-2016-069708.TIF ■
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'.Yt\ - Sulxh-ision AVIAN WOODS REVISION
��- Iniironn ptd)i� ItI,D,'innm -
�r IN 372011652484
PO Box X59, 10t1 Southwest Bled.Newton.NC ?RGSS 1.0I1f 18
NAME.ON PERMIT: MARK KIEFER, 4657 GLEN HOLLOW LNNE, HICKORY NC 28601
0 Site Address: . 1075:HARPER LEE DR, NEWTON NC 28658 ` t
t Property Size: Square 6ttc 58,370.40 Aerer 1.34
Directions: take 321.N towards hickory/Take Startown Rd exit// 331 Turn Right/go 4 Miles/turn.Right onto Milton
• Street/turn Right on-harper Lee/House on right
•
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( Owner/Au thorized.RepresentatiYe A eltnoytIed gent ent of Permit Receipt
- ,,b-I cenify that'Iram the ovnier or authorized agent-(owner's authorization required)representing the owner of the-
- ;property described above. - -
1.
t
4 �/' As the property owner or authorized representative, I have received the above referenced permitls)as I
i requested in the application Tor set-vice RBPR-02-2016-23127 , by the tel method(s):
Received in Person j
f acsiniihe Transmittal (Rettim (ono with signature required) `
f Electronic Image Transmittal/E-mail (Return receipt,required)
y J�As the proptit> owner'of authorized Iepicscntatiy'e I have reviewed and understand the specific conditions
of this permit issued, and hither understand that all applic iblc regulatory requirements speciticd under the North
C'ii'olmq Liiws and Ruler for SthVII.V.Trea tntent and Dicpneat Systems (I5:. N'CAC ISA .1900), and/or
Well Construction-Standards (15\ NC AC 2C .0100), shall apply to the issuance of this permit and the
I $
• construction of the wastewater system and/or water supply well permitted. t
Permit Issue Date: 03/02/2016
owner/Authorircd Representative Signatore� a � n� /
1 Date N a4• .
•
Documentation of I'erniit(s) Transmittal
(perrnit transmitted by electronic or other means)
Permittransmitted by .k,n-;- o_ fl ,-0. (`tune of person sending pernrir}
•
Signature -,..:�.. � arrs. • Date/Time S et /G 1_ll'
Method: Fax _I niail_U,SMail jAl1ize Other
Owner's rcqucst-do-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: i
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anpennh' O3/Oi/21116 OS:i6 I'eee 4014
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gA CATAWBA COUNTY D �° rti f 0 Case# WELL-03-2016-069708
/3","' Public Health Department � Jai. Subdivision AVIAN WOODS REVISION
OY Environmental Health Division • PIN# 372011652484
PO Box 389, 100-A Southwest Blvd,Newton, NC 28658 ° .:� i • LOT# 18
/842 ,u _ : •FA
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O °r ' ~U
NAME ON PERMIT: MARK KIEFER, 4657 GLEN HOLLOW LN NE, HICKORY NC 28601
Site Address: 1076 HARPER LEE DR, NEWTON NC 28658
Property Size: Square Feet: 58,370.40 Acres:1.34
Directions: take 321 N towards hickory/Take Startown Rd exit# 33/Turn Right/go 4 Miles/ turn Right onto Milton
Street/turn Right on harper Lee/ 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 (I5A NCAC 18A .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.
Robbie Phelps 03/02/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 03/04/2016 08:17 Page 1 of 3
Catawba County Environmental Health Aht11- ',- Za( - 06470 %
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*Pressure manifold tap sizes:
-Use 1/2"schedule 80 taps to supply the 54 and 50 foot drain lines.
-Use 1/2"schedule 40 taps to supply the 62 and 58 foot drain lines.
-Use a 3/4"schedule 80 tap to supply the 70 foot drain line.
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Parcel: 372011652484, 1076 HARPER LEE DR 1 in=60ft
NEWTON, 28658
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 iufrn mation 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 2014 Catawba County NC
03/02/2016
WELL CONSTRUCTION RECORD For Larne/Use ONLY:
Tidy farm em be wed For single or multiple wells
I.Well Contractor Information: •
Ashley T. Moretz uiwA :.
FROM TO uc4[:mr19oK
Wet1Cn ictor Natne R f 0 0 R /6 P"
2586-A Y.2o R Y7r 200 6 An.
NC well Convector Certification Nu:4er .IS OtrrER CASINGIrer maidcaeatwdht;oknm:Q_QS Me)
FROM TO MAMMA THICKNESS MATERIAL
Moretz Well Drilling ' 0 n 6o R _6 .5a'a-/ "VC-
Company Name r� 1 N-@FNRtt CAS@1G;OR7'OB1 onrran storeap?.. .. .
3 -0L 03 DMMErga nitcTQ0SS MATERIAL
2.Well CtCVbJC dm Pe+mit#: W V R fo
Lett all walkable wit coamrusrivn permits(Le.Cowrt'Slate,variance.err:)
n R is
S.Well Use(check well use):
Water Supply Well: racist to ownernte mai"Size
Ttaanscis MATWAt.
OAgliadtural OI`MlnicipalPublic R
OQeotbermal(HeatinglCooling&apply) kSRcvid ntial Water Supply(singlo) n m.
Ofndusbial/Co mtadal OResidearial Wass Supply(shmcd) 18:GROU7:... .. .. :. _ - .. .
OIm,Gation FROM TO MATOLIAL EWPLAcEM&NT METHOD 4c AMOUNt
Non-Water Supp1y Wen: 0 fL 20 ft l_e .+-' toast-rl
❑M m onitoring • ORecov ft. R
Inaction Well: ft D.
CJAquifer Recharge ❑Groundwater Remedied= 19:SANDIGRAVEEPAaCfifeppniable)
. FROM TO MATERIAL a ELACET rnrMEmoo
❑Aqoiler Storage and Recovery ❑Salinity Barrier _ -
°AquiferTest OStormanter Drainage n \\`—sRa
❑Experimental Technology OSuhsidcnce Control a
OGeothemtal(Closed Loop) ❑Tracer Fn:URl I4?t5 LOGleaactSddt allvDt lea liotcawry) ,.. .
FROM TO DFSatlYrJQfiIc ar.banineir,senhIp4 um Andy doe nth.
❑Geothermal(HeatinpfCooliog Return) °Other(explain bide'421 Remarks) 0 R SD n- Co 1AJ(, / -gym 4-4_
3,Date Well(s)Completed:3- Wen tDfk 5Q f` non to O//G,C
rt. rt.
Sa.Well Location: n
fp�
/nark it Ie.7er m ,
R
Fxilily/thnwTNeme Futility 11:1#(if appVie3k) R n
/076 JIarfcr ,Ce_e. Pr- /t/e_44/iv". R R
Nysieal Addrew,City,and 1p
ZL REMARKS .
la4r.t,.rckt. 37aQ/J6c Vfy
Canny Parcel Identification No.(PIN)
Sb.latitude and Longitude in degrees/minutedlse ondsor decimal degrees: .
on
(if well field, e LvAong u sufficient) 22.Certlilation:
35• 467,211 N .8/. 02 62578 w �7f /i ' 3�3/6
. // Sigtmrmeoa flag Weil Coacoctor Data
6,is(are)the bens): �mmnent or °Temporary
wt'
stoke Ws f0 1 hereby that . 0J has ewa accordance
p IA NC 02C_0100 or ISA NCAC I2 020 Well Cocegn doa Standards and that a
7.Is this a repair to an existing well: .Oyes or 9C cop)of this re cordh us bee n provided to the well amen
qwi,is a rgnW,fll ant down well cnnmtctiat ieafarnmtroa and captain the warn,of the
repmr ander(121 restart section or on we beet ofwufonn. r 23.Site diagram or additional well details;
B.Number dwells constricted: j You
may USC�r�wi this page to provide additional well site details or well
Forma may also attach additional pages if necessary.
hiple injecrioa or non-watermppfr wells ONLY the same mmnnden you nem
=ban melanin (�p SUBMITTAL INSTUCIIONS
9.Total well depth below land surface: 7 O .(ft,) da- For AP Welly: Submit this form within 30 days of completion of well
For mablple welly a at,all dgdhs ldp em(eranrda-0@200'and 2(g)001 convection to the following
10.Static water level below top of casing: 5-0 (ft) Division of Water Quality,Information Processing Unit,
If water level Is above taring.use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) Mb.For Injection Wells: In addition to sending the form to the address in 24a
n above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: nr r 1Ar✓ construction to du following.
tie.anger,=very,cable,direct push.etc) rr
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n / lit 1636 Mal Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm) r-9...0 0 Method of tam R Cr /t r 1 �.For Water Sufmly R leU ctien_Welb; lo addition to sending the toms to
/,� / the addrbs(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Cr ( Amwnt /4 o compledor.of well construction to the county health department of the county
where coresnbcted.
Fenn QW l North Carolina lkpmnrnt of Envimnrrcnt and Natural Resources-Division of Water Quality Revieal Jan.2013
Td Nd67:80 ST OE PO '-Idid ZZZTZ977aL : 'ON xdd dWild E 112M Z13aOW : NO