HomeMy WebLinkAboutWELL-05-2016-072548.TIF .v,A CATAWBA COUNTY Case#
,Q �7 Public Health Department Subdivision AARON H LAIL
4:4•®1, ;1 Environmental Health Division PIN# 460703143889
"'1' • PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOT, 3
/842 sr
NAME ON PERMIT: WALTER REYNOLDS, 3638 W BAY DR, SHERRILLS FORD NC 28673
Site Address: 3826 LANDMARK DR, SHERRILLS FORD NC 28673
Property Size: Square Feet:21,780.00 Acres:0.5
Directions: HWY 16 SOUTH TO HWY 150 EAST, LEFT ON LITTLE MOUNTAIN RD, RIGHT ON LANDMARK DR, 2/10 MI
ON RIGHT
Owner/Authorized Representative Acknowledgement of Permit Receipt
10/2 I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
1,(27? As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in e application for service RBPR-04-2016-23725 by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
W/, As the property owner or authorized representative I have reviewed and understand the specific conditions
Ni
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: 05/19/2016
ter! thorized Representative Signature ate S- 24' - 20%6
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson 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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dspcnnit 05/19/2016 10:28 Page 3 o13
11 #
Y \ CATAWBA COUNTY O ;o Case WELL-05-2016-072548
sac) Public Health Department Ng" r I• Subdivision AARON H LAIL
• } PINK
�t Environmental Health Division ti, �r 460703143889
IF3 ab 9 PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 G g•o � '� LOT# 3
1842 { P.
\AA
•0,1 of
NAME ON PERMIT: WALTER REYNOLDS, 3638 W BAY DR, SHERRILLS FORD NC 28673
Site Address: 3826 LANDMARK DR, SHERRILLS FORD NC 28673
Property Size: Square Feet:21,780.00 Acres:0.5
Directions: HWY 16 SOUTH TO HWY 150 EAST, LEFT ON LITTLE MOUNTAIN RD, RIGHT ON LANDMARK DR, 2/10 MI
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 we/l.
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 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.
Jason Boyd 05/19/2016
AUTHORIZED STATE AGENT APPROVAL DATE
elipermit 05/24/2016 10:54 Page I of 3
.03A- r Permit d I. RBPR 4-16-23725
/V 2- CATAWBA COUNTY Name Walter Reynolds
Yn� 2 Public Health Department y
'""°'"►.r: Environmental Health Division Address ' 3826 Landmark Dr Sherrills Ford
NC
tli p PO Box 389, t00A Southwest Blvd.Newton NC 28658
PIN# 460703143889
18 . 2 w (828)465-8270 Fae (828)465.8276 TOO(828)465-8200 -
Site Plan Authorization to Construct
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5 EKWELLDRILLING PAGE 01
0 m WELL CONSTRUCTION RECORD 7 4.1.7--/b
m For Internal Use ONLY:
This form can he used rix.single or multiple wells
1,Well Contractor Information:
Robert E Teague 14.WATERZONE9 r
9 FROM TO 1 DESCRIPTION
Well('pnuaclar Name
2857-A •
,i-.5,5-ft-.5,5-ft /6'd t. .o 6 /�an
rt. n, LI
NC'Wdllbmoonr('eniliearion Number •
FROM
Kit 2'.. .,;,�..,,j;;; _OR•LN R ef,;;;a;„4,r,a.
FROM TO DIAMETER TMICleNESS MATERIAL
B & K Well Drilling Inc. may( 0 n 2 0 ft 61/8 l"• SDR-21 PVC
Company Name 'Construction Permit 0:pronto
/ (� FROM TO
t1R �� DIAMETEft. ft. R THICCKKNESS 'MATERIAL',
3.Well 2.Well f
l - rel.plhohl net/ fun(boor \rate Variance.ere./
p rt, in.
Use(check well use):
Water Supply Well; FROM TO DIAMETER Sl OT SIZE THICKNESS MATERIAL
ft. ft.
OAgricullural ❑hyinicipal/Public
°Geothermal(I leating/Cooling Supply) 1. esidential Water Supply(single) ft. ftin.
_. . ..,,. . . .. ......
❑Industrial/l onfinercial GReiic(entlal Water Supply(ShnIDd) FROre. m MaQin'TO MATERIAL EMPLACEMENT METHOD a AMOUNT
pin'ipatio" 0 ft 20 n' Hole Plug Pour/Hydrate
NomWatcr Supply Well;
It. rt.
°Monitoring CRccovcry
Injection Well: rt. ft.
°Aquifer Recharge OC3roundwater Remedialion -19r6AtO cIhIDEPAClf,'MajssleMdd' 'FROM _ TO MATERIAL EMPLACEMENT METMOD
°Aqui(r Storage and Recovery ❑Salinity'Barrier nIt.
❑Aquifer'real GStormwater Drainage n f
°Experimental Technology °Subsidence Control
20..DRILLINB L0234.9ttpch attiiihMted fusel (RMFa.RSI)" " '
°Ge I berinal(Closed Loopl °Trager FROM TO 1 DESERIPT.TN(eola,.hard Ppll feWR[h ryyt101n OM.co.)
riCtenthtrmal(I leubng/Coobng Return) °Other(explain under A2 Remarks) Q R 3 . f° 2-. + a ,/•\//
ll 1 —/ r �(/���
/� ?.] 3 C h. h, rJ1 cl S�'f- /21e.
4. Dale Welles)Completed: / ' .1D.I r6weI11DM n, 1-'' n,
SA.Well I,ocafi° Nki rt. n.
lnll/L) Ic! PL//lllli3 le ft.
faeiliry10wnel Saint Facility 104 IiC epplitabkl
n. ft.
35'(1.0 Lair Mrkr^A 1)r Sherh/'
Physical Address.City.and Zip :21.REMA.RKS.. .:. ""'-"'` ' ' ..'
--A±A kish.
r'tm'uy parcel Identification Ni,.(PIN)
blatitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C Ito
bewail hold_one las9nng iv..ullicien0
N w J� �'']�' �) >--2a —/G
Signature ntCenhied Well t.onrrac Or Y Date
6.Is(are)the wettest: 0 Permenen I or °Temporary
Hy netting IIsi,form, 1 hereiv ter/tn.that Ma wul/(r)wase/I (were)roti re Iec In sand that
,ens ISA Ni at OA•.6/On or ISA P('AC112C.H2011 WeO(Lnllnrcr;un.Aundurlh and thuja
7.Is this a repair to an existing well: 0 Yes Or JNo copy opho a<mN Isar Seen provided to Inc nn/I ounur.
I111n, ,u,elhm.fin oui known well eonnrvcoon,n/hrnlplgm sod cxnlain the nature of the
nymlr under'1 remark,,emmn or tin M,,hock ry1b„form. 23.Site diagram or additional well details:
I You may use the back of this page to provide additional well site details or well
H.Number of wells catatrucled: f constluetion details. You may also attach additional pages if necessary.
I'iv nnrdieWe mjerran tin non-u dear supply well,ONLY with The Name ronmucrirm, env run
.uhmll roe Thom SUBMITTAL IN.STIICTIONS
9.Total well depth below land surface: " ',y/r 5 (ft.) 24a. For All Wells: Submit this (Orin within 30 days of completion of well
Id✓mumps.',c t soall,enth,II enflUr AI(eoompl•.31/211/I'and ATOM) cons I melt to the following'.
10.Static water level below top of casing: 50 (fry Division of Water Quality,Information Processing Unit.
/I''vater Incl a anntr cavny ,..r-•• l 6 1 7 Mail Service Center,Raleigh.NC 27699-1617
II.Borehole diameter: 6 On.) 24b.fur Infection Wells: In addition to sending the form to the address in 24a
Rotary above. also submit d copy of this firm within 30 days of completion of well
12.Well construction method: construction lu the following:
H
I.ntLcr rotary,cable.direct push,ctc./
Division of Water Quality.Underground Injection Control Program,
FOR W ATF,R SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh.NC 27699-1636
13u.Field(gpm) 4_0 Method of lege Open Flow 24c For Water SRDDIV dr Iniectlon Wells; In addition to sending the form to
the addressees) above, also submit one copy of this form within 30 days of
Chlor Tabscompletion of well construction to the county health department of the county
131a.I/lslnfcenon type: Amount: 1 1/2 Lbs
where constructed.
Io.m OW-I Nola;Carolina Oepsrtmmn atEnvirun mem and Natural Resources Division of Water Quality Revived Jan.2013