Loading...
HomeMy WebLinkAboutWELL-04-2016-071586.TIF ssA--cn CATAWBA COUNTY Case# Public Health Department Subdivision 4 )Y Environmental Health Division PIN# 368902581117 "4191 PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOT# 2 /8.2 su NAME ON PERMIT: JOSEPH LASALA, 116 KILBORNE RD, MOORESVILLE NC Site Address: 5467 THREE SISTERS LN, CATAWBA NC 28609 Property Size: Square Feet:43,560.00 Acres:1 Directions: travel N on Sherrills Ford RD, Turn S on Buffalo Shoals RD, 1/4 mile turn left onto Battle Run Community, right onto Muskey DR at the end on the end Owner/Authorized Representative Acknowledgement of Permit Receipt gmI certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. -FAs the property owner or authorized representative. I have received the above referenced permit(s) as requested in the application for service RBPR-04-2016-23604 by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/E-mail (Return receipt required) gorrAs 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: 04/26/2016 N1 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 eltpennit 04/26/2016 08:41 Page 4 o14 s�A CATAWBA COUNTY Q • "I 0' S Q Case# WELL-04-2016-071586 Q Public Health Department iQ Environmental Health Division ision r ti • Subdivision PIN# 368902581117 'Ls; PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 IV. 4. LOT# 2 18.2 • Q • •�O .O NAME ON PERMIT: JOSEPH LASALA, 116 KILBORNE RD, MOORESVILLE NC Site Address: 5467 THREE SISTERS LN, CATAWBA NC 28609 Property Size: Square Feet:43,560.00 Acres:1 Directions: travel N on Sherrills Ford RD, Turn S on Buffalo Shoals RD, 1/4 mile turn left onto Battle Run Community, right onto Muskey DR at the end on the end 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. 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 04/26/2016 AUTHORIZED STATE AGENT APPROVAL DATE ehpenuit 04/26/2016 08:42 Page 1 of3 -.- 07 1517 L-n7 it wkir,.a ,l..:i A, 1..,i . -.!t.ti flit t.,-.r't# ri .. ,;.,,! w_[ II- V-7 of 6 iJ 0 no -pp y, 265.37 J, y Z CL S 9 1 . 4 4-T. 0- \s/ , /. �' / / �ti/ wt 1 I 45 'V / / iT /� s s Hiv1.fV 5.. 4� i ti o i no pit ° ; � 1 v-,� 1 265 5 t N \ k 55 l t t t \ \ ',.0 Parcel: 368902581117, 5467 THREE SISTERS 1in=50ft LN CATAWBA, 28609 This map/report product was prepared from the Catawba County,NC Geospattal Infon nation 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 u ter.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 04/25/2016 May 25 16 12:05p Advanced Well Drilling, L 8282412445 p.2 WELL CONSTRUCTION RECORD Fw Internal Use ONLY: This hen can he used for single or multiple wells a 1.Well Contractor Information: Michael W. Shaw le.WATER ZONES IlLEMMININES DESCRIPTION Well Con�sor Name /(t/// avt- 3232 2 15.OUTER CASING for mStl led with OR LINER If a..livable NC Well Contractor CeniOcoliov Number MILMIIIIIIIMIIIMIll THICKNESS MATERIAL Advanced Well Drilling, LLC (> ft. nin..111 Heavy PVC Company Name 16.LNNER CASI G OR TUBING •-.thermal closed-bo• mP Y I / t THICILVESS MATERIAL 2.Well Con4ruttion Permit ft: L/d1-04-. 2O/I,- /};v n• O. =n. List all applicable well nautrac:ion prangs(ie.Coenry.Stole,Varrwrte,vac) rt. R lo. 3.Well Use(cheek well use): IT.SCREEN Water Supply Wen: FROM TO DIAMETER IlanICI. MATERIAL fL ft, lo. _- GAgricu[tuml OMtmicipallWblic K R, n. -- :Geothermal(Heating/Cooling Supply) eResidrntial Water Supply(single) Dlndusfrial/Commacial ❑Residential Was Supply(shared) to GROUT To MATERIAL LMPL\CF,MPNr METHOD A AMOUNT ran°Irrigation � ,t- fL Bentonite Poured Non-Water Supply Well: ft. ft. ❑Monitoring °Recovery rt. ft. Injection Well: :Aquifer Recharge °Groundwater Remcdiotion 19.SAND/GRAVEL PACK Oa.•liable CIIME TO MATERIAL EMPLACEMENT METHOD :Aquifer Storage and Recovery °Salinity Barrier fr. O. °Aquifer Test DStormwater Drainage fa ft. ❑6xperimcnml Technology ❑Subsidence Control 20.DRILLING LOG attach additional streets if necessary ❑Geothe:mat(Closed Loop) DTtacer ' MISS TO DESCRIPTION caar,ea • sail/stick n• • In an.ma °Geothermal(Hea5ng/Cooling Return) DOiher(explain under 1121 Remarb) R. 7 ft. ' r ����/// ��� ?r i rt „a c- 4.Date Well(s)Completed:. 7�/6Well IDtf R. R 5a.Well Location: 114 / 0. iL ` eSir'(I V1 5(( `rt rt. rt. Eacilily/fOsvn <Naae Fa/Ci hey lfnd(if applicable) R. ft. 5.y G n7 -R1 rrc Se4cU�� [ r, ft. ft. Physical Address,City.and Zip 21.REMARKS 6j*4.ccJbCr - 3(5-e1O ryir1 7 Cormty Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce -.ratios: Of wen field,we taUlung is sulDrirnp /(, ?5013': aa3 NO ) CO4 19\19 W ' (A7 eS .lc° Signature of Certified Well Contractor Date 6.Is(are)the well(s): 18Permanent or °Temporary By signing this form 1 hereby cen&that the cello ons(were)era unreled in accordance with 15,4 NC/C 02C.0100 or 153 NCAC 02C.0200 Well Conirna-lion Siandank and that a 7.Is this a repair so an existing well: DYes or D?fo copy of ibis record has been provided rode evl/caner. if this it n repair.fill out known well constrrrl+oe inf rsaran and explain she nature of the repair wider ell remarks rerrfon or on the hack aphis form. 23.Site diagram or additional well details: 1 You Flury use the back of this page to provide additional well site details or well 8.Number of wells constructed: =motion details. You may also attach additional pages if necessary. Far mtdtiple lrjection or non-rratersupply wells ONLY with the saint eotetrunisa,you can SUBMITTAL INSTUCEIONS submit one fora. 9.Total well depth below land surface: 5'2 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For mnldple wells list all depths if stiffen*(eeom&e-3©200'and 2@¢)00) construction to the following Division of Water Quality,Information Processing Unit, 10.Stalk water level below top of W lag: / (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 If',vier level s above sexing "*" ���/// II.Borehole diameter: 6 (inJ 24b. For Injection Wets: In addition to sending the form to the address in 24a • ;yam �j_ above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: di le 1° ON `ei N construction to the following: (i.e.auger.mmry.nblK direct Posh,etc.) ✓ Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Censer,Raleigh,NC 27699-7636 Air 24c.For Water Supply&Injection Wells: In add stun to sending the form to 13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of HTH uum: a'' /� uomplaien of woll oonmeuclion to the county health department of the county 13D.U751DieCDDn type: Am where constructed. FormOW-I NorthCarolina Department of Envitanment and NaruroI Resources-Division of Wass Quality Revised law.2013