HomeMy WebLinkAboutWELL-04-2016-071395.TIF •
,A • CATAWBA COUNTY Case#
,n:-.7 �y Public Health Department Subdivision AVIAN WOODS PH 3
< 194e; s, Environmental Health Division PIN# 372012953881
.PO Box 389, 100-A Southwest Blvd.Newton,NC 28658 LOT# 40
is.2, +m
NAME ON PERMIT: *KEVIN D. & SHANNON L. FULLER, 1322 THURBER LN, NEWTON NC 28658
Site Address: 1322 THURBER LN, NEWTON NC 28658
Property Size: Square Feet: 74,966.76 Acres:1.721
Directions: Startown Rd, South from HWY 70 to left on Milton ST veer left on Milton and take a left on Thurber. Lot is on
the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
WI I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
4 As the property owner or authorized representative. I have received the above referenced permit(s) as
requested in the application for service RBPR-04-2016-23612 by the following method(s):
IReceived in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
AyrAs 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: 04/20/2016
Owner/Authorized Representative Signature t�_wl\� "
Date 1-1 liS 1 Ila
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
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chpemtit 04/20/2016 10:24 Page 4 of 4
"— f Case#
A CATAWBA COUNTY o„ , . 0 WELL-04-2016-071395
•
./ Public Health Department Subdivision AVIAN WOODS PH 3
Environmental Health Division .•
1 'r PIN# 372012953881
PO 13os 389, 100-A Southwest Blvd,Newton.NC 28658 ` LOT# 40
1842 s. . -r r • A
0 .41 O
8'0
NAME ON PERMIT: *KEVIN D. & SHANNON L. FULLER, 1322 THURBER LN, NEWTON NC 28658
Site Address: 1322 THURBER LN, NEWTON NC 28658
Property Size: Square Feet: 74,966.76 Acres:1.721
Directions: Startown Rd, South from HWY 70 to left on Milton ST veer left on Milton and take a left on Thurber. Lot is on
the 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 (I 5A 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.
Megen McBride 04/20/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpermit 04/20/2016 10:25 Puee 1 af3
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FROM : MORETZ WELL & PUMP FAX NO. : 7044621322 Jun. 29 2016 04:33PM P2
WELL CONSTRUCTION RECORD For!mortal Usc ONLY:
This Crum can be used for single or multiple wells I
i .
1.Well Conmaeror Information;
tr:UAWATERiIZONE51da3.£r FS;rl Ja I ':`-'..`r n a Ste:;e
Ashley T_ Moretz FROM TO DESCRIPTION
Well Contractor Name a 90 n' zy s{L /4 Dh--
2586-A ;4'0 k y9S R'_ Lo 6`Pro
NC Well Contractor Certification Number ,,:imovriltessiNG'((mmWd'shed 'a➢e1:ORT SRiit- -— ble, "-:'•` F';`q
MROM TO DL\METER TH K'KNESs MATERIAL
Moretz Well Drilling Orr' 79 rL 6y8 iw $6A-.2,j I Pvc
77,wir rgsweA3LCtoluire9INRairisiilobaoo-r m 5 ..?qd^301
Company Name
O/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: -201 6 —07/3 6/ ft Le i°'
LW all opplrcaMe well permits(i.e.County,Skate.✓onane2,Infection.err I
IL
3.Well Use(check well use): :Y7..SCREEN). :`:.1 t .r.-..=...:. (-..rs9•t., tr. "„ 'e`)i(
Water Supply Well: FROM TO DIAMETER SLAT Sur THICKNESS MATERIAL
O ft
D.4gricuimrsl f,2Municipal/WMic
in.
DGeothermal f catin Conlin 6 Supply) atdentid Water Supply(Single) ft
❑Industrial/Commercial °Residential Water Supply(shared) i=1&'BROUITAil t`;Ir 12'&r'c?.y 2S', /vuy+ws'2'`"D'tl grd l Y,>, ti'X, T '2.b.fLi j!f^4
FROM T'n Mn't'ERInL EMDI.ACEMENTMEfHODd AMOIPrf
°Irrigation O ft. AZ 0 R Apr r ' icAµ
Non-Water Supply Well: ft R
°Monitoring °Recovery
Injection Well: - - — ft n
°Aquifer Recharge °Groundwater Remediat ion PlEiSANn1(SRA.vrRL'P OCIHPapySeahla)a Aida:: ,. .A'.3 L x ,us.,.-;:'v .A
FROM TA MATERIAL EMPLALTNGYI'METHOD
❑Aquifer Storage and Recovery °Salinity Barrio ,
°Aquifer Test OStormwatet Drainage
h.
DExperimental Technology ❑Subsidrnx Control i7Lv, ,taNC4IOCe 4afSSEIh'Sd'diSaia4eh2iti If aecntsyq S c'.'HS9 t A JsSd%S la+
DGeolhermul(Closed Loop) °Tracer FROM TO DESCRH T1ON(color,hardnev,eniUrack re,grain wu,nn)
°Geothermal(Heating/Cooling//Return) //°Other(explain under 021 Remarks) Q D• 701 R LI), .Se�
4.Date Well(s)Completed: p”/J J4)Weli IDk /Q n' �0S 2 (J O.
Sa.Well Location: n. It.
kevAA d- SA&Afnen A4//er R ft.
Facility/Owner Name Pncilisy[no(if applicable)
/3r7�1 // LI 2 R
.2a 7hfnrber L,/ it. n.
Physical Addre..c City,end Zip
6,,-hl,w4a, 3701 O/p2 9.53 SS/
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: '
(if..aulfieelld,one Luang is suffc ent) d �..p p T /A( ` / T
35, fe(as55 R N O�, a J o 3 la W G 4e fraC h�7,—/.3
� //
Signature of C ed ll Con eor Dotc
6.Is(arc)the well(s): %d manent or CTemporary By signing this pm, I hereby certify that the we'll")'vac(were)constructed in accordance
��
wean/54 NIIAC OXD.OIon or ISA NCAC 02C.0200 Well Cnnsovcrtan Stnadmde and that n
7.Is this a repair to an existing well: Dyes or NNn copy ojthis record has been provided to the well owner.
If Ors et a repco.PO out i own well construction Infarmwton and explain rite namsc of me
repair under n21 remark,section or on 0m lack gfthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or moll
g.Number of wells constructed: / construction details. You may also anach additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same een ouctlon,you can
submit one form. t SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft) 24a. 1/or All Wellg: Submit this form within 30 days of completion of well
For multiple wells lin all depths Ifdiij eras,(example-?@,200'and 2rW100') construction to the following:
10.Static water level below top of casing: O (ft) Division of Water Resources,Information Processing Unit,
sfwarer/evr/sr above caring,arc - / 1617 Mail Service Center,Raleigh,NC 7749Y-1617
II.Borehole diameter: 6 (in.) 24b. For Infection Weill ONLY: In addition to sending the Corm to the address in
nn r 24a above, also submit a copy of this form within 30 days of completion of well
11 Well construction method: e7t T go T`r v construction so the following:
(La.auger,rotary,cable,direct push,etc.) /
Division Of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Air 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gum) 1 Method of test. r l( fT/ 24c.For Water Supply&Injection Wells:
Also aubmn one copy of this Lorin within 30 days of completion of
1314.Disinfection type: M rN Amount: /S' 0 2 well construction to the county health department of the county where
constructed,
Font GW-I North Carolina Department of Environment and Natant Resource%-Division of Water Resources Revised Atigusl 2013
•