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Home My WebLink AboutWELL-05-2016-072230.TIF x.i.X5. CATAWBA COUNTY Case# • . Public Health Department Subdivision GEORGIA PARK ; er Environmental Health Division PIN# 366703321831 �'-a6 / PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 18 NAME ON PERMIT: KAREN RICE, 3532 MELDONNA DR, MAIDEN NC 28650 Site Address: 3532 MELDONNA DR, MAIDEN NC 28650 Property Size: Square Feet:20,037.60 Acres:0.46 Directions: 70 East Conover Blvd East/turn right on Emmnanuel Church Rd/turn right on NC 16 S/turn left on NC 16 South/turn right on Buffalo Shoals Rd/turn right on Meldonna/lot on right Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative. I have received the above referenced pennit(s) as requested in the application for service RBPR-03-2016-23370 by the following method(s): Received in Person eacsimi1e Transmittal (Return form with signature requi lectronic Image Transmittal/E-mail (Return receipt required)red) As 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: 05/10/2016 '2Owner/Authorized Representative Signature Date Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted ay , 4, 1.,111 IS .11_, 1'_ (name of person�s nd'ngperm' Signature ,w�1 I'ill�' L ' an AB Date/Time I I I CO 30 Method: Fax \_fr‘iilUS Mail Other Owner's request o send by the ahoy- indicated method of transmittal in lieu of signature 10 I e 1. li ISLL t We want to hear from you. Please • ake a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EHCustomerService ehpenuit 05/11/2016 10:04 Page 3 of 3 SSA CATAWBA COUNTY 0 r o r}.f o Case# WELL-05-2016-072230 • Public Health Department .. r .. Subdivision GEORGIA PARK < : ,c Environmental Health Division f•' �T • PIN/ 366703321831 t2 .0 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 ro LOT# 18 84 Uri—WV u old, ' NAME ON PERMIT: KAREN RICE, 3532 MELDONNA DR, MAIDEN NC 28650 Site Address: 3532 MELDONNA DR, MAIDEN NC 28650 Property Size: Square Feet:20,037.60 Acres:0.46 Directions: 70 East Conover Blvd East/turn right on Emmnanuel Church Rd/turn right on NC 16 S/turn left on NC 16 South/turn right on Buffalo Shoals Rd/turn right on Meldonna/lot 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 (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 05/10/2016 AUTHORIZED STATE AGENT APPROVAL DATE (Alumina 05/1 1/2016 10:08 Page I of 3 4th -s-2 - D-7221( Catawba County Environmental Health w.„l ( -5-_2oi6__ 07 2ti • 0 t41 hr T , a u -4 a /14rf.m} DLO • ,1 A) s, /,u,,72_ n,e I A ivcw — 30_ Pr 1 2,- Lo 6- tx. x-NN.N. *4111P4 Zy fr 1.3`7 JCc..✓✓ "CO r 04,45 /i L" • R tre fir o- • `/i 2 /24tn• \ Parcel: 366703321831, 3532 MELDONNA DR ` 1in=40ft MAIDEN, 28650 This map/report product was prepared horn the Catawba County,NC Gerispatal Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or date on this report.Catawba County promotes and recommends the independent verification of any data conNined on this map/report product by the user.The County of Catawba,tts employees,agents,and personnel.disdain,,and shall not be held liable for any and ell damages,lass 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 0 511 0/201 6 r This form can be used for single or mu ltiple wells ( I 1.Well Contractor Information: 1....�++✓"'� °" jg VC'Y�+y AA �r '14.WATER ZONES lea' C� t cS FRO}t TO DESCRIPTION ' \Nell Contractor Name ` 956 ft. , 37 ft: �+''� y ft. .ft. NC Well Contractor Certification ae 15:OUTERCASING(for multi-cased wells),ORL1NEW(if applicable) , FROSt TO DIAMETER THICKNESS MATERIAL. � (' a '1rd,R' i a ft. 26 ft. / ,.;.2.5.-in. 1.1)9..).- 1 f, Company Well CDnstrue#ton Permit t I 16,St f R CASING OR T BIND eoth'rmal closed-loo P y U (� rif ., i FROM TO DIAMETER THICKNESS MATERIAL I.it sat1app ltcablewell permits(ze.Cows .State. Variance, etc) ft. ft. in. 3.Well Use(check well use): t7 SCRE @I\ Water Supply)Yell: - FROM Ti) DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. i OAgricultural ❑Municipal/Puhlic 1 ❑Geuthermai(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. [Industrial/Commercial: ❑Residential Water Supply(shared) O ROIJT TO • MATERIAL EMPLACEMENT METHOD&AMO _r. UNT 1 0 Irrigation 0 ft. 96 ft. 125,70=7—' Pe).-Water Supply Will: to ft. ft. I" - - ❑Monitoring ❑Recovery Injection Well: ft. ft. infer Storage and Recovery ❑Saline d Barrier Rej ation :FRO t VD/GRTO EL PAf`K1(;fATERI tilcl ❑Ag riedl MATERIAL EMPLACEMENT METHOD DAq - b y ity t [Aquifer Test ❑Stomiwaler Drainage ft.. ft. ❑Experimental Technology flSphsidence Control ""20;DRILl"ING`LOG(attach=`additional sheets if necessary)", °Geothermal(Closed Loop), UTracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.) ji ❑Geothermal(Heating/Cooling Return) ❑Other(explain.under#21.Remet'ks) 0 'ft. °'70 ft 4,Date 3Ve11(y)Completed:. °'. ! 7/1<4 I.1f1# 'b ft 3t/� ft: L?_�C ft. ft: c 3 5a.Well Location: ft. ft. ft. ;ft. facility/Owner ( �j Facility ID#(if applicable) p ft. ' / .'7 + i1 9(, 0'.1/'►till`Y 4r s ft. ft Physical Address,City,and �.Zip �/ /'"f �p L Wvl T • r er 6 6 + 6sn/14/ ,..21.REVIARIiS County t - Parcel.Jdtntificatioin No.(POT) Sb.Latitude and.Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica on: j(if well field,one List/tong is sufliment)c J�'3t/',� ' ', N 8"/O gS ! 32 '' �' 1 Siena of Certifi d Well Contractor Date 6.Is(are)the well(s): OPermanent or ❑"Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 114 NCAC 01C.0100 or I/A NC'AC 02C'.02011.Well Construction Standards and that a 7.Is this a repair to an,existing well: ❑Yes or ❑NO copy oflhim•record has been provided to the welfowner. (phis is a repair,fill,out known wellrconstruction information and erplain the nature of the repair under#11 remarks section or on the back of thin.form.. 23.Site diagram or additional well details: You may use the back of this page to provide:additional well site details or well S.Number of wells constructed: construction details.. You may also attach additional-pages if necessary. For Multiple injection or non-water supply wells ONLY with the same construction,you can submit one form. SUBMITTAL INSTUCTIONS V 5‘5 . 9.Total well depth below land surface: �- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths tf different(example-3@200'200'and'210100') construction to the following: 10.Staticwater level below top of easing: (ft.) Division of Water Resources,Information Processing Unit, II-water level is above casing,use"-i 1617 Mail.Service Center,Raleigh,NC'27699-1617 U.Borehole diameter:, (u.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in 24a above, also submit'a copy of this form,within 30 days of completion of well 12.Well construction method: Q:,*( construction to the following: (i,e,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR.WATER SUPPLY WELLS'ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield;(gpm) C"f Method of test:, 24c.For Water Supply&Injection Wells: Also submit one copy of this form within 30 days of completion of 13b.Disinfecr3on,type; Amount: well construction to the county health department of the county where constructed.