HomeMy WebLinkAboutWELL-04-2016-071070.TIF tir" 1'
�,$ CATAWBA COUNTY 0 �� • i 0 case# WELL-04-2016-071070
f� Public Health Department �' ` �•I Subdivision•
PIN#
d ' 't Environmental Health Division r a"{4i ..r 3 378001176911
� PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 r LOT# 2
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NAME ON PERMIT: ROBERT D. & CHERI W. PAYSOUR, JR., 1746 CORDIA CIR, NEWTON NC 28658
Site Address: 1465 LOFTIN DR, CATAWBA NC 28609
Property Size: Square Feet:87,120.00 Acres:2
Directions: Murray's Mill Rd /Troy St/ Raynell St/ Loftin Dr/on left
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. EUILDNG FOUNDATIONS 25 FT.
2 . EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT.
9 . 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 I8A .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 04/12/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 04/12/2016 10:29 Page I of
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Catawba County Environmental Health 741/1-11 - Li- Zo(d- 071043
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Parcel: 378001176911, 1465 LOFTIN DR 1in=60ft
CATAWBA, 28609
this map/report product was prepared tram the Catawba County,NC Ceospadal Information Services. Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained Cr'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,disCaim,and shall not be held liable for any and all damages,toss 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
04/11/2016
e' ‘°1 RESIDENTIAL WELL CONSTRUCTION RECORD
r_11 o
1 i0' yq ( North Carolina Department of Environment and Natural Resources-Division of Water Quality
CONTRACTOR
' ' WELL ACTOR CERTIFICATION# 2 GS( —
1.WELL CONTRACTOR: g. PJ/ATER ZONES(d h
TONY R DAVIS Top I//o Bottom 'L Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING - Top Bottom Top Bottom
Well Contractor Company Name Thickness/
1481 LARRY DAVIS ROAD 7. CAS NG: Depth � Diameter Weight Material
Street Address • Top / Bottom ST Ft 24 1.5 Cement
LAWNDALE NC 28090 Top Bottom -FL
City or Town State Zip Code Top__Bottom Ft
( 704) 276-3434
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: //��''���� �] Top Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT-Da. r�c- Top Bottom Ft.
OTHER ASSOCIATED PERMIT-Cif appArable)
Top Bottom Ft
SITE WELL ID#(8 app6®ble) 9. SCREEN: Depth Diameter Slot Eta Material
3.WELL USE(Check Applicable Box: Residential Water Supply s" Top Bottom Ft. In. _ in.
Top Bottom Ft In. in.
DATE DRILLED '^
- / Top Bottom Ft In. _ in.
TIME COMPLE I ED ( AM❑ PA4p�
10.SAND/GRAVEL PACK:
4.WELL LOCATION: ,/('f,��1 Depth Size Material
CITY:( 4 W bA COUNTYe�4'l wbA Top 0 O Depth Ft 78-M Gravel
!'S 5 tor M.) DJ t 2 SGo Top Bottom FL
(Street Name,Numbers.Community,Sdrdmsi Lot o.,Parcel,Zip e) Top Bottom Ft.
TOPOGRAPHY!LAND SETTING: (check appropriate bat) 11.DRILLING LOG
❑Slope kaeilley ❑Flat ❑ftidge ❑Other 'Top Bottom Formation Description
LATITUDE j,t�er r XX
'' - 'DMS OR 3X. X.roOWO(DD /
•
LONGITUDE/ :' DXe 'DMS DR 7X.xxx'000OOL DD /
Latitude/longitude source: '-f-'S Dropographic map /
(location of well must be shown one USGS lope map andattached to /
this form if not using GPS)
��1 /
b. O Nyy ER 9p��u g I e0 Name /9
-
Street,Address AJC- 20.6 a 5
City or own State Zip Code • /
( ) /
Area code Phone number . 12, REMARKS:
6.WELL DETAILS: -
a. TOTAL DEPTH: ,
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: /t; Fr. •ACCORDANCE WITH I5A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
/_, PROVIDED TO THE WELL OWNER.
d. TOP OF CASING er iat% w l Above surface Land Surface _ r^,rt I 6 •3. 16
Top of casing terminated at/or below land sudam may require .�/l�ALr.1. W
a variance in accordance With 15A NCAC 2C.0118. SI NATU F CE ISI TED WELL CONTRACTOR DATE
a. YIELD(gpm): METHOD OF TEST TONY R DAVIS
V. DISINFECTION:TypeC4R( Amount 110Zr PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mall Service Center,Raleigh, NC 27699-161,Phone:(919)807-6300 Rev.2/09