HomeMy WebLinkAboutWELL-05-2016-072344.TIF '— �
,T3A CATAR'BA COUNTY 0• 4 o cr. Case# WELL-05-2016-072344
p % Public Health Department r. Subdivision LIZA STAFFORD HOUSTO
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tr- PO Box 389. 100-A Southwest Blvd,Newton, NC 28658 4 0 ti i LOT,/ 6•
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NAME ON PERMIT: DONNA BAYNE, 1271 TURTLE DOVE RD, CONOVER NC 28613
Site Address: 4272 BETTY'S HOLLOW RD, CONOVER NC 28613
Property Size: Square Feet:49,658.40 Acres:1.14
Directions: Lee Cline turn right onto Stafford St turn right on to Betty Hollow Rd
Last 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 (I5A 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 05/13/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpenuit 05/13/2016 09:17 Page 1 of 3
P, (dc, WE.IL 9-611-61-1.i4-)36)5
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ZnS�G II 100amllon sep-hr, Yantc ar,d 30044. of )5))o Redacts ; 9-754. -f rend,e ,
* Tnssall drain fiead on Cone
* Se is system mos+ be a1 lean- So f -From welts, 104 -frpM vorell lines, and
From sdructoces, indockivq decks and porches . Ceep 9skcM of bE riayt-o1 ajs
and easete n-IS. I �J
* Do no{ Jr (,l 5cade, Col, or -Fill o'Jer seitic, areas.
157.4.
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.30' wall
Arm 5a'
4' welly/musk be (A} `le<<�y� : j\m„
5a{t. -iron ser{ic S\0{ems C 4,6
proposed 3 Beam MH 45'
)5f1- "rpm Siruc{aes. ' . „a
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- 5-11. from copal' lines ,
Keep well ov{ of easernerrls
and fit \-of- ways.
tok
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139,5•
B41ys /4o11ow Rd.
®lin 20 16 08:04p Russell Welling Drilling 8286322617 p.1
EP
IPrint Form I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Russell II.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
•3245A
60 "- 265 fr-
H. ft.
NC Well Conlrador CH-tit/cation Number 15.OUTER CASING(for multicasd wells)OR LINER(If ap i 1'walrle)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft" 90 ft- 6.25 m. SDR21 PVC
Company Name 16.IM4ER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction ble nei c Permit ti:
WELL-05-2016-072344 FROM TO DIAMETER THICKNESS MATERIAL
Lim al;applicable..eJi ron.rtrucrian permits(i.e.WC,County.Scare, Variance.etc.) R- fr. 1°'
3.Well Use(check well use): R fn. in.
Water Supply Well:
FROM SCREEN
lr�tJJtl Ppy FROM TO DIAMETER SLOT SUE - THICKNESS MATERIAL
Agricultural D Municipal/Public fL R. in
Geothermal(Healing/Cooling Supply) OResider.[iat Water Supply(single) ft.
QlndustriallCommercial DResidcntial Water Supply(shared) is.GROUT
fllnlgation FROM TO MATERIAL EMrr.ACEMENT METIIOD&AMOUNT
Non-Water Supply Well: 0 n 29 f1. Grout Poured
. .Monitoring DRecnvery ft. R.
Injection Well:
B. ft.
Aquifer Recharge DGmundwater Rcrncdiation
19.SAND/GRAVEL PACE(if applicable)
Aquifer Storage and Recovery ❑I Salinity Harrier FROM TO MATERIAL FMe1AcRMA\T METHOD
Aquifer Test DSro:mwater Drainage ft. ft.
Experimental Technology Subsidence Control R. ft.
Creolhermal(Closed Loop) DTraccr 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIMION(DIM.hardness.sell/rack rope gran size,arc.)
Gcothamal(Hcatinp/Ctwling Return) QO[hen(explain under 421 Remarks) 0 ft 85 n- Dirt
4.Date Welt(s)Completed:05/31/2016 Well 11)11 i 85 ft. 265". j Rock
ft. fl.
5a.Well Location:
Donna Bayne f` ft.
Facility/Owns Nairn Facility lDE,(if applicable) H. ft
4272 Betty's Hollow Rd, Conover, NC 28613 R- fL
Physical Address,City,are Zip R. ft.
Catawba 21.REMARKS
County Parcel ldentificationNo.(PIN)
5b.Latitude and longitude in degrees:minutes/seconds or decimal degrees:
(if well field,one Iatlong is sufficient) 22. rib- ation:
35' 45.130' N 081' 12.491' w /
i 06/20/2016
6.Is(are)the well())0RPermanen or QTcmpnrary ignature of Ccrtif^!R'dl Cenwnor Dam
By signing this form. I hereby certify that the weil(s)was (were)constructed in accordance
7.Is this a repair to an existing well: DYes or OH No with ISA NCAC 02C.0100 or 15A.NCAC 02C.020) Well Construction Standards and that a
If this is a repair.Jill out known well construction information and noisen the nature of the copy of WS)record has bean Provided so the well out er.
repair under t•21 remarks station or on the back al thi fans. 23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having lac same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
F.,rmuley le well.ISO nil depths sfd17erent(example.3 @200 and 2/100') construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,information Processing Unit,
/,owner level is abase rasing.mr"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In addition to sending the 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 construction method: construction to the fallowing:
(ie.auger,rotary,cabin,direct push,cm)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Sent Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air 24c.For Water Supply Sc Injection Wells: In addition to sending the faro to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 2/3 cup completion of well construction to the county health department of the county
when constructed.
Four GW-I North Carolina Department of Environmental Quality-Division of Water Resourws Revised 2-224916