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Home My WebLink AboutWELL-05-2016-072349.TIF ,v, CATAWBA COUNTY Case# . -- . - .v fl,y Public Health Department Subdivision d im3 0.4 IY Environmental Health Division PIN# 364807579865 PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 LOTH 1 182 sw NAME ON PERMIT: JACOB KILLIAN, 1513 PRISON CAMP RD, NEWTON NC 28658 Site Address: 1513 PRISON CAMP RD, NEWTON NC 28658 Property Size: Square Feet: 104,108.40 Acres:2.39 Directions: Hwy 321 - Prison Camp Rd g past the 4th house on the right- paved road by a cow pasture Owner/Authorized Representative Acknowledgement of Permit Receipt \ VI - pr/operty certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the XJ " described above. lyy� As the property owner or authorized representative, I have received the above referenced permit(s) as fV requested in t e application for service RBPR-04-2016-23572 by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/ E-mail (Return receipt required) \/ As the property owner or authorized representative I have reviewed and understand the specific conditions F. 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: 05/13/2016 , Owner/Authorized Representative Signature 7\ Date 5//0/40 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 ago 05/1312016 09:55 Page 4 o14 CATAWBA COUNTY � 1r o Q Case# WELL-05-2016-072349 g y� Public Health Department Subdivision 6 ��t Environmental Health Division 15. r PIN# 364807579865 K''+f' PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 0 LOT 1 18.2 ry :y,r, - NAME ON PERMIT: JACOB KILLIAN, 1513 PRISON CAMP RD, NEWTON NC 28658 Site Address: 1513 PRISON CAMP RD, NEWTON NC 28658 Property Size: Square Feel: 104,108.40 Acres:2.39 Directions: Hwy 321 - Prison Camp Rd g past the 4th house on the right- paved road by a cow pasture 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 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 timefratnes 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. Jason Boyd 05/13/2016 AUTHORIZED STATE AGENT APPROVAL DATE ehpennit 05/13/2016 09:55 Page I of3 c CATAWBA COUNTY Permit# EHPR 1-16-23050 � Name Jacob Dale Killian 2 ublic Health Department Address 1513 Prison Camp Rd Newton < r Environmental Health Division N;C PO box 389, IOOA Southwest Blvd, Newton NC 28658 PIN# 364807670722 /842 ym (828)465-8270 Fax (828)465-8276 Tut)(828)465.8200 Site Plan Authorization to Construct .� Frtf•n 0 1 R ,L-4- ,.! (ri c.a."? r ... V„— Lc( cy0 0_c_. A D cap R Ib5 V 11 2 ACC 1 w ��{S v b ti' 1 35 �3.?E Y (-0Q IIY-0— zs' f t rp. i L. rp.rl 1(0 51/ ,57 -- nla-,a °r‘ ..,C. . ) V Io, - - -- -- - - - - P.'s ir iillr„ A perox 2. 0U ro C-.r LL. V V Scale 0 I • 130 16 02:22p Russell Welling Drilling 8286322617 p.1 10 s•, IPrint Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Chris Russell 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name 40 ft 405 ft- 3245A ft. rt. NC Well Contactor Certification Number IS,OUTER CASING(for multi-cased wells)OR LINER(if ap licable) Russell Well Drilling, Inc. FROM TO DIAMETER TIIICKN'ESS MATERIAL Company Name 0 ft. 112 t. 6.25 in' SD R21 PVC WELL-05-2016-072349 16-INNER CASING OR TUBLNG(ecotlurmal closed-loop) 2.Well Construction Permit#: FROM ' TO _DIAMETER THICKNESS MATERIAL List ail applicable well eanstrtction permits(i.e.U1C.County.State.Yariance,etc.) LL ft. in- , 3.Well Use(check well use): ft. ft 1° Water Supply Well: SCREEN FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL III Agricultural DMtmicipaVPublic ft ft. in 1 Geothermal(HcatinglCooling Supply) r3Residential Water Supply(single) ft. a in. 111,1ndustriaL'Commercial DResidenlial Water Supply(shared) 18.GROUT IrrlRation FROM TO MATERIAL : EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 IL 20 ft- Grout Poured ii Monitoring ®Recovery IL IL Injection Well: ft. II. 11 Aquifer Recharge ®Groundwater Remedietion 19.SAND/GRAVEL PACK(if applicable) al Aquifer Storage and Recovery 0 Salinity Bonier FROM TO MATERIAL F.MTLICEMP.Nr METHOD — ii Aquifer Test 0 Stotrnti<'ater Drainage ft f II Experimental Technology ®Subsidence Control IL ft. :Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary) FROM TO DESCRIPTION(color,hardness,solVrsek type.grain saze,de) mi Geothermal(Hearin:Conlin_Return) IIII Other(ex t lain under#21 Remarks) 0 It' 107 f° Dirt 4.Date Well(s)Completed:07/25/2016 Well io# 107" 405 ft Rock ft. ft. 1 Sa.Well Location: Jacob Killian-Clayton ft. 1 FncilityfOwner Name Facility 1Dit(if applicable) ft ft. 1513 Prison Camp Rd, Newton NC 28658 fL ft. ft. ft. Physical Address,City,and Zip Catawba 21.REMARKS County Parcel Identification Na.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lel/long is sufficient) 22.Certife lion: 35' 37.189' N 081' 12.109' W 07/25/2016 tyalaturc of Ce ed ell Contractor Date 6.Is(are)the well(s)OPermanent or DTemporary By signing this form,1 hereby certVy that the welks)war(were)constructed in accordance 7.Is this a repair to an existing well: [JYes or %DNo with 15A NCAC 02C.0100 or 15A,NCACO2C.0200 Weil Construction Standards and that a U.this is a repair,fill out known well construction information and explain Ike nature of the copy of this record has been provided to the melt owner. repair under 321 remarks section or on the hack of this 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..For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary. construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 405 (ft-) 24a-For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths(fdfferenl(example-3€.200'and 2 @100') construction to the following: 10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit, If-writer level is above casing,use'•+" . 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 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(gprn) 1 0 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount- 1 CUD completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016