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Home My WebLink AboutWELL-06-2016-073422.TIF �t CATAWBA COUNTY Case# WELL-06.2016-073422 Public Health Department Subdivision �'t p I PIN# 277003229296 tc , �. '1 Environmental Health Division PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOT# 2 NAME ON PERMIT: MELISSA JILL CURTIS, 1070 ROLLING RANCH DR, HICKORY NC 28602 Site Address: 1116 ROLLING RANCH DR, HICKORY NC 28602 Property Size: Square Feet:21,780.00 Acres:0.5 Directions: Advent Cross Rd, George Hildebran Rd, left on Camp Creek Rd, left on Oren Stephens, left on Rolling Ranch Dr 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 T property described above. / As the property owner or authorized representative, I ave received the above referenced permit(s) as requested in the application for service , by the following method(s): _ Received in Person facsimile Transmittal (Return form with signature required) lectronic Image Transmittal/E-mail (Return receipt required) (As the property owner or authorized representative I have reviewed and understand the specific conditions 7- 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: 06/14/2016 fJiu,._____3 Owner/Authorized Representative Signature Cu4w- Date //V Ilp Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by • ,u IsA A, ■ ,th (name of person sending permit) Signature At T ' 1r�i_ ' Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature fn Oi k t We want to hear from you. Please take a f moments to complete our customer service survey at: http Wwww.surveymonkey.com/s/E1-1CustomerService e14=00 06/14/2016 08:53 Page3 or3 y;,SS CATAWBA COUNTY 0 G Ir..• 0 Case# WELL-06-2016-073422 C' f Public Health Department Subdivision t. Etld:�� M Environmental Health Division ° 'O ° PIN# 277003229296 4\\\\\\\\\\,'8 PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 is LOT# 2 ! Z i J + { ). • onto NAME ON PERMIT: MELISSA JILL CURTIS, 1070 ROLLING RANCH DR, HICKORY NC 28602 Site Address: 1116 ROLLING RANCH DR, HICKORY NC 28602 Property Size: Square Feet:21,780.00 Acres:0.5 Directions: Advent Cross Rd, George Hildebran Rd, left on Camp Creek Rd, left on Oren Stephens, left on Rolling Ranch Dr 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 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. Steven Price 06/14/2016 AUTHORIZED STATE AGENT APPROVAL DATE • dim miit 06/14/2016 08:53 Page I of3 EHPR 05-2016-23965 1116 Rolling Ranch Dr,Hickory • New well should be 5 ft from property lines; 25 ft from structures; 50 ft from septic systems; and out of right-of-ways and easements. • The septic system for this lot appears to cross the property line onto property that is owned by the same owner. An easement needs to be provided so that the septic system goes with this lot. 1 °r 195J ` I 3 r H ' tsik °Y 07/13/2016 08: 36 7048924705 EKWELLDRILLING 0 ii PAGE 01 • /Me 40-01) ' SleVG YL J �a WELL CQNSTRUCT!ON RECORD (or�rnal Use ONLY: P. This form can hr used for single or multiple welli i I.Well Contractor Information: • 14.WATER ZONES • Robert E Teague FROM I TO I DESCRIPTION Wen Con,re.n,.Nem. 2;9 n. 2 C�• 1-7 ly H, 2857-A rt. A. NC'Well Coniracto,Cod ncmion Number Is.OUTER CASING(for mold'cared wek)OR LINER(if anplkabe) FROM TO DIAMETER THIC$9CSS MATERIAL B & K Well Drilling Inc. 0 ft 0 n. 6 1/8 I"' SDR-21 PVC 16.TINKER CASING OR TUBING(geothermal cloud-loop) ' Company Nunn FROM TO p1AMC FR THl %N SS MATERIAL. W ell Construction Permit d: U 1.)J 7 1^7' ft. ic In rue uu opplic<mlr tt ell o,nrnrdn,t rerndrs p.r.rannn.score,Ibr;unre.end R e- In. J.Well Use(check well use) 17..SCRETt'I _ FROM TO DIAMETER I SLnT SIZE I THICKNESS MATERIAL.Water Supply Well' n. n, m. ❑Agricultural OM lc ipal/Public ft. ft. in.°Geothermal(Ideating/Cooling Supply) esidential Water Supply(single) •pindus[rial/Comm<rd01 °Residcnliol Water Supply(shared) s.GROUT • PROM TO .MATERIAL EMPUCEM ENT METHOD b AMOUNT °Irr■gation — 0 ft 20 n' Hole Plug Pouf/Hydrate Non-Water Supply Well: D. rt. UMonitoring °Recovey ■ --- Injection Well: ft. n. I 0Aquifer Recharge °Groundwater Remediation 19-SAND/GRAVEL PACK Of applicable) FROM I TO MATERIAL EMPLACEMENT METHOD °Aquifer Store at and Recover) °Salinity Barrier ft. et. °aquifer Test DStormwater Drainage n - ft. • [IExperimenlal Technology ❑Subsidence Control au DRILLING LOG(atach.adidaml then*iffaaaley) OGcothcnnal(Closed Loop) °Tracer FROM 1 TO I OrsCMPnON:camels • t,,wv •ek type.r1,rte.nc.I °O0Orhermol(Healing/Cooling Return) °Other(explain under a'_I Remarks) r it' 19 R. a 0 a - 4,Date Wdllsl Completed:/-1 - ir+ Well Wit L�1 AI ' _• - L- iI, rt. S .Well Location: n. n. i . 7 L _ s - 0, n. I , • FacililvlOwner Name r Faciliry IDA Ill ap1pli�cable O fi 1 I ; �QJ i 1 tic �S G✓v- �'1 >?r 1-1!eel i - 1 IL n. Physical Address.Clry,and Zip 121.REMARKS Cowin; Favor!ldcati,cAtion No.(PIN) 51).Latitude and Longitude In degrees/Minutes/seconds or decimal degrees: 22 Rcatio urwnn vela one I]OIOOE r6 sufficient lr / /' N W ?- 7- gumre ofCernfied Well Contra-to Dam 4.Is(are)the well(s): OPermanenl or °Tempos ly y,„xnrnp'iv,'il�rm.I hereby ruro/i Thor the,reu/,)Iray(were)eunsm,rreJ in oc:nrJmn- C/( nmO 154 M'A('Ill('.II 00 ter car! 'A('U7( 0200 W.11(bminrd,mr Standards 0•d rhm n 7.Is this•repair to an existing well: °Yea Or No e'pr•ifih:.,veuril hen nee•pnnid:d to the Neu nn.mr. Irm/';,n r:gvr./10 nnr known sun,re'lr corning nrn rn(nrmonun net erpl„m the nan,n 0'the 23.Site diagram or additional well details: rnpaie',Mier'.,2/renmrk,,mmw iv on the hack,,Vito Inns g You may use toe back of this page to provide additional well site details or well g.Number of wells constructed; construction deails. You may also attach additional pages if necessary. For mabpn'e INcdlnn np nonmmrr n,ppin a ell,Oct..)'nerh the,one 5unwrae+l1n..1'011C(111 • .nbmh n,re rnrt, 1 SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: !l '�� (ft.) 24a. For All Wcllg: Submit this form within 30 days of completion of well For nudorie wem list au;kith,N,// . 'feenn'pb-3esi,) nx 26re„foil) construetionto the following: 10.Static wafer level below top of casing: 50 p g' (ft.) Division of Water Quality,Information Processing Unit, 1617 Mail Service Center,Raleigh,NC 27699-1617 ' //nicer/ere ry r•.MO:<roxnrp luu”. II.Borehole diameter: 6 (in.) 24b. For Iniection Wells; 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 nveil 12.Well construction method: Rotary construction to the following: the alga.rotary.cable.direct push.etc.) ' Division of Water Quality.Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636 139.Yield m Method or testa Open Flow 24c. For Water Suntily a Inieclifn Wells: In addition w sending the font to (gpm) the address(es) above, also submit on: copy of this form within 30 days of Chlor Tabs 1 1/2 Lbs completion of well :onstruction to the county health department of the county 13b.Disinfection type: Amount: where constructed. Fore,ow-i North Cnrolina Depanment of Endmnmem and Natural Resources—Diaisiou of Water Queliry Rc r,sed Ion.2012