HomeMy WebLinkAboutWELL-03-2016-070331.TIF rr •r.
`,yYi • CATAWBA COUNTY p case a WELL-03-2016-070131
iPublic Health Department L. Subdivision
/ tr 73 ir PIN# 374407793311
`-`� Environmental Health Division 447.1.1..��9® Y �
'� PO Dos 389. 100-A Southwest Blvd. Newton. NC ?8658 LOTH 2
1.42 s. r., T •
NAME ON PERMIT: DUSTIN SIGMON, 1794 LINDSEY LN, CONOVER NC 28613
Site Address: 1794 LINDSEY LN, CONOVER NC 28613
Property Size: Square Feet: 126,324.00 Acres:2.9
Directions: Hwy 16 North, Left on Springs Rd, Left on Rector St., Left on Lindsey Lane & lot is down the road 1 mile on
the left. # is on mailbox
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 l-lealth 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 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.
Steven Price 03/22/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 03/22/2016 15:00 Page I o13
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Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Russell
Is.WATER ZONES
WcltCmtragnr Name FROM i Tn OESCRII'IiON
3245A 50 It• 225 ft'
rt. ft.
NC Wall Contractor Certification Number
15.OUTER CASING(for malts-rased wee)OR LINER(if sip'licahle)
Russell Well Drilling, Inc. PROM 10 DIAMETER THICKNESS MATERIAL
Company Name 0 IL 60 t'- 6.25 '°- SDR21 PVC
WELL-03-2016-070331 16.INNER CASING OR TUBING(pmOwrmal clneed-loo10
2.Well Construction Permit n: FROM 10 I DIAMrrnn THICKNESS Mnn.Rot.
Liss all appheahle AlLmnm..rrhsn permits he 111C.Cm.nry,State,Variance,rte) to EL ,n.
3.Well Use(check well use):
L ft. I in.
Water Supply Well: U.SCREEN
FROM TO DIAMETER SLOT SIZE I TItCKNINS MATERIAL
D Agricultural D MumcipalfPublic R. it In i
O Crwlhcrmal 0leating/Cooling Supply) OResidential Water Supply(single) rt. ft. hi. '
Industrial/Commercial f Residential Water Supply(shared) -IL GROAT - _
Irrigation FROM TO I MA111WAL I EMPIACLSIENTMETIIODR AMOUNT
IL IL ' Grout Poured
Von-Water Supply Well: 0 20 I
H Mmtitoring DR,aovcry fl IL I t
Injection Well:
L
Aquifer Recharge DGtoundwater Reinedia:inn I
It.SAND/GRAVEL PACK((I applicable)
Aquifer Storage and Reeovcry DSaliniry Barrier
FROM TO MATERIAL EMPIAf,RMICST METHOD
Aquifer Test DSmmmwuter Drainage rt. D.
DEapaime-ntal Technology 0Subsidenec Control IL i IL
J G»thermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets it aeenna)_--
FROM TI) I DESCRIPTION Nobs.hardaeu sail/rack type graisdre etc)
,!}Gat Amos Musing/Cooling Return) DOtha(explain under#21 Remarks) 0 fL 55 t'' I Dirt
4.Date Waits}Completed:04-19-16 Well IDs 55 IL 225 IL I Rock
•
5a.Well Location: n R.
Dustin Sigmon-J.Wood fL ft- l
Facility/Owner Name Facility 10161 applicable) ft. ft. I
1794 Lindsey Lane, Conover NC 28613 ft' ".
•
Physical Address,City,cad Zip it R. i .
Catawba 21.REMARILS I
Cou,.b Paced Identification No.(PIN) — I
Sb.Latitude and longitude in degreLS/minulesfseconds or decimal degrees:
(if well fold,one belong is saftrictu) 22-C'•ifieuti
35' 47.346' N 081' 12.087" W '� - 04/21/2016
6.!stare)the well(s)IPermanent or DTemporary .ijmMine ofCni6.• c .m,rracmr Dux
Hy signing this form.1 hereby comb)thin the well(..)war(were)coesar'het in accordance
7.Is this a repair to an existing welt: DFes or %DNo with 15A.9CACO2C.0100 fir I5A S'CAC 02C.U260 Well Cancseaedon Smmlardc and that
U this Is is repair.fIi ouLtnovn,s ((Ctarhactins information and explain the nature anise Copy of Mit record hoe heist provided to the well ownet
repair ender 021 remarks archon or on the hack of this form.
23.Site diagram or additional well details;
R.For Genprobe/DPf or Closed-Loop Geothermal Wells Laving the same
You may use the back of this page to provicc additional well site details or well
mnstnelion,only I GW-i is needed. Indicate TOTAL NUMBER orwells construction details. You may also attach additional pages tinecessuty.
drilled- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (It.) 24a. For All Wells: Submit this :ore within 30 days of completion of well
For multiple welt list nil depdu II-different(esample-3C-'00'and 2 @100) consmetion to the following:
10.Static water level below top of easing: 50 (D.) Division of Water Resources,Information Processing Unit,
Iweer-lead is above Canny,USC"t" 1617 Mull Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in:) 24h.Far Injection Wells: In addition to sending she form to the address in 24a
Air Drilled above,also submit one copy of this form within 30 days of completion of well
12.Well enslruction method: construction to the following:
t.e.auger,rotary,cable,direct push.em.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1634
13a.Yield(gpm) 10 Method of test:Air 24e_For Water Supply& Injection Wells: In addition to sending the form to
the addrms(es) above, also suhmil one copy of this form within 30 days of
136.Disinfection type: HTH Amount 1/2 CUD Completion of well constriction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Entimmncntal Quality-Division of Water Resources Revisal 2.22-2016