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Home My WebLink AboutWELL-06-2016-073439.TIF qc�� 4. CATAWBA COUNTY Case# rat Public Hrahh Department Subdivision Y tie, Environmental Health Division PINN 379102750494 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOTM 2 PT 3 t. NAME ON PERMIT: CHRISTOPHER & KATIE TAYLOR, 6268 LONG ISLAND RD, Site Address: 2257 GLOVIER RD, CATAWBA NC 28609 . Property Size: Square Feet:523,155.80 Acres:12.01 Directions: Take Hwy 10 toward downtown Catawba, Right onto Hudson Chapel Rd, Property is on the Left at the Corner of Glover Rd & Hudson Chapel Rd. If you reach Brown Chapel Rd you have gone too far. 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 /x property described above. a- As the property owner or authorized representative, I have received the above referenced permit(s)as requested in the application for service EHPR-05.2016-23885 by the following method(s): Received in Person acsimile Transmittal (Return form with signature required) y Electronic Image Transmittal/ E-mail (Return receipt required) Vi t. 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 (1SA NCAC 18A.1900), and/or Well Construction Standards (1SA 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: Os/14/2016 —Owner/Authorized Representative Signature f `J Date (91 (5 I i Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit trans itted . . !u 'M, t •Al. 1 _ (name of person se Odin permit) �j •Signature I,Dd .1.t 11_, I, Date/Time J IO° Method: _Fax Etnail_US Mail Other Owner's r quest to send by the above indicated method of transmittal in lieu of signature ��Y We want to ear from yo� e a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EHCustomerService' • ehpennit 061i4/2016 09.59 Page 3of3 s$• \ CATAWBA COUNTY 0 : 17— a Case# WELL-06-2016-073439 t2 Public Health Department Subdivision �m HC Environmental Health Division r PIN# 379102750494 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 1g LOT# 2 PT 3 18.2 sa • jo 0 NAME ON PERMIT: CHRISTOPHER & KATIE TAYLOR, 6268 LONG ISLAND RD, Site Address: 2257 GLOVIER RD, CATAWBA NC 28609 Property Size: Square Feet:523,155.60 Acres:12.01 Directions: Take Hwy 10 toward downtown Catawba, Right onto Hudson Chapel Rd, Property is on the Left at the Corner of Glover Rd & Hudson Chapel Rd. If you reach Brown Chapel Rd you have gone too far. 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. Jason Boyd 06/14/2016 AUTHORIZED STATE AGENT APPROVAL DATE ehpennit 06/14/2016 10:00 Page 1 of3 EP Permit# EHPR 5-16-23885 `� • CATAWBA COUNTY u- Q G Name Christopher and Katie Taylor j a g Public Health Department is Apt/iJ Address 2257 Glovier Rd Catawba NC d It% 28609 4 Environmental Health Division !• / PO Box 389, 100A Southwest Blvd,Newton NC 28658 �84��ym (828)465-8270 Fax (828)465-8276 TDD(828)465-8200 PIN# 379102750494 Site Plan Improvement Permit / ti) 1 I --) I Grt. 0 T..,k ,. loo 11..:1 . 1 S 3 5, 7Qe..� � 3 be 12 it L. - cpa r Ar_� 1 f l— / -03 2s 7,e) 3 b loo' OPENI rT1-.Zi Th l J I 9 l p b \ J V 3 5R 1 pit, J3or\ CLaP-- I 2 � 1 213 e , 4- Lac— -{-, e -\ a 1 1= l O o t Scale i �+•Sr�a R ivt, ,;,.: : s DENTIAL WELL CON T;,U ION RECORD .4?�� V/Yr Rallr, North Carolina Department of Fnvironmcrit and Natural ILesources•DI'Vt�totl or wive(Mit' ... w WELL coNTR4CTOR CERTIFICATION 4 INA ,..2. . 1.WELL CONTRACTOR: �/ ,� g. WATER ZONES(de th): `' / /��<<4j 44 J Top 7 O Bottom �a Top Bottom Well Contras r(Individual)Nagle I // Top Bottom Top Bottom � ,A,/d110_Company ((//JA /A f Top /C) Bottom S4 7(9 Top Bottom Well Co dor me Thickness/ ?V J /7 . j 7. CASING: Depth Diameter Weight Motorist,// Street 7-1d ,dtl/ ! . 4-z/z/l � /'� �- � V� 1 Top. Bottom Ft / �U c City or T.• n State Zip Cade Top Bottom Ft. Area code Phone number B. GROUT; Depth tanal thud 2.WELL INFORMATION: 35�3 Cr Top Botfam�&_Ft. WELL CONSTRUCTION PERMITi/ d Top Bottom Ft Zt OTHER ASSOCIATED PERMITI.()f appicab) Top Bottom Ft SITE WELL ID diff appteable) 32 9. SCREEN: Depth Diameter Siot Slze . Material 3.WELL USE(Check Applicable Box): Residential Water 5uppld Top Bottom Ft in. in. DATE DRILLED ,e7' ,. / t�idJ Top Bottom Ft. in, In. Top Bottom Ft. in. in. TIME COMPLETED 474 i _ AM o PM6 10.SAND/GRAVEL PACK: 4.WELL LOCATION: -- —. / Depth Size Material CITY: COUNTY �t (� f.11t'lrt Top Bottom Ft. S .- , r C Top Bottom Ft. (Street Nnme.Numbers.Community,Subdivision,Lot No..Percet Zio Cede) Top Bottom Ft. TOPOGRAPHIC I LAND SETTING: (oiled(approprmte sox) 11. DRILLING LOG ❑Slope _ValleyOlat r3 Ridge DOther Top Bottom Formation DeacnpitOn LATITUDE "DMS OR 3X.XXXXXXXXX DD / 6/� / /J/ „_,1<' LONGITUDE LONGITUDE ”DMS OR 7X.XXXXXXXXX DD / f I/ /"../LC ��S( Latltuderongitude source: [3PS OTopographlc map / /rocetion of well must be shown one USGS topo map&reattached to l J� �� this form if not using GPS) 1 6.WELL OWNER . i � ,eI � , Owner Name / Street Address / & 7-(x___ AC . s-6doi / City or Town State Zip Code ( Fa2.8 3/5--' /6o-i, / Area code Phone number 12. REMARKS: 6.WELL DETAILS: a, TOTAL DEPTH: - ---/5-(-2 b. DOES WELL REPLACI?EXISTING IAfELL7 YES 0 NCira) I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: ‘c O Fl. ACCORDANCE WTH 15A NCAC 2C,WELL CONSTRUCTION (Use''+"If Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED THE WELL OWNER. d. TOP CASING IS Ff.Above Land Surface* �_ I /.f/J//j l// 7 O /6 'Topp of Casing terminated allot below land surface may require a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED W�EELLLL CONTT(RACTOR a. YIELD(gpTl). 7 METHOD OF TEST 41/C Lc/M/ r/ O&-de-1/ Yj( (4X- .5S�// f. DisINFECTION:Type �TTj� Amount_' o NTED NAW OF PERSON CONbiHUCTING E WI71 Submiiihe onginst to the Divisron crOVatit.Catilittsiii0iiit3O days„,Afdi:_Fi> httwuOf }},,, Form GW-1a 16'7'Mal)laervicb Cettt r=ttalelgh,N 2+849-T1k .•Phoria,No (919)80**10lif;; l r4 j,it Rev,11/08