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HomeMy WebLinkAboutWELL-06-2016-073805.TIF y;4 ,• CATAWBA COUNTY Case# ,f' ct."11y Public Health Department Subdivision 4e1 4 Environmental Health Division PIN// 366702880506 PO Box 389, 100-A Southwest Blvd. Newton,NC 28658 LOT# 2 /g.2' :+ NAME ON PERMIT: *AMERICA'S HOME PLACE/ STATESVILLE, 1206 GREENLAND DR, STATESVILLE NC 28677 Site Address: 3654 N OLIVERS CROSS RD, NEWTON NC 28658 Property Size: Square Feet:40,946.40 Acres:0.94 Directions: HWY 16 S, N OLIVERS CROSSROADS, LEFT PAST RUHAMA CHURCH RD WILL BE OPEN FIELD WITH MAILBOX#SIGN FOR 3652 Owner/Authorized Representative Acknowledgement of Permit Receipt . ,. certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the frrty described above. • /As the property owner or authorized representative, I have received the above referenced permit(s) as . requested in t 'e application for service RBPR-06-2016-24078 by the following method(s): . Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal! E-mail (Return receipt required) IIAs 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 (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: 06/22/2016 Owner/Authorized//Representative Signature �7-��, Date �/—zz` / 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 We want to hear from you. Please take a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/EFICustomerService ehpermit 06/22/2016 13:48 Page 4 of 4 ;For ' Case# s� \ CATAWBA COUNTY D �. o O WELL-06-2016-073805 .f' ru.'Im,\G Public Health Department ;�:, Subdivision 4 { 4 `'' Environmental Health Division '.5. PIN# 366702880506 '�'1 1 1 e!-2 PO Box 389, 100-A Southwest Blvd, Newton.NC 28658 -�+ � LOT# 2 s4 /� t - .-J 1S . :"'=ZC {•G NAME ON PERMIT: 'AMERICA'S HOME PLACE/ STATESVILLE, 1206 GREENLAND DR, STATESVILLE NC 28677 Site Address: 3654 N OLIVERS CROSS RD, NEWTON NC 28658 Property Size: Square Feet:40,946.40 Acres:0.94 Directions: HWY 16 S, N OLIVERS CROSSROADS, LEFT PAST RUHAMA CHURCH RD WILL BE OPEN FIELD WITH MAILBOX#SIGN FOR 3652 WELL PERMIT WATER SUPPLY: Individual Well SETBACKS: 1. i UILDNG FOUNDATIONS 25 FT. 2. _::ISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT. 3. _:-:ISIING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 4 . Sr/WAGE PUMP SUPPLY LINE 50 FT. 5. UNDERGROUND STORAGE TANKS 100 FT. 6. STREAMS/BROOKS/CREEKS 50 FT. 7 . LASES/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. II: te 'vclI 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 Regardit,a, Private drinking Water Well Testing (I5A NCAC I8A .3800). The fee for this sampling is included in : .c c tst of the well permit. It is the applicant or property owner's responsibility to notify Environmental I!c.t!th 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 Severn! different reports concerning your water sample. For questions or more information, please contact Catawba County Environmental Health at(828)465-8270. i'ol'hic Phelps 06/22/2016 AUTHORIZED Si .....:AULiU L APPROVAL DATE ehpennit 06/22/2016 13:49 Page I of 3 4 '. " 6 - 2a(G - 07380 [f b tU - 6 - loll- 073805 3SY // 0livsw.r (roJp kJ , _ p:441,,9,., Ibs 70 L So M \\\ 6 \ ��-,Ieo -- �'a �, /ao �— Id' o 3 nit - 9" Al vfs_ -- N)-w 4 S r"/". 62" L, a • N a . in c' k r -e i 4 L1�i ir.., /8/ , F ys 60 - . f �5,s� v '''''.'4”7'044-',. u 4ws tiE,y' 1 � B' -- �w -: .'.'�bnry R c� � 1Aae.<..�m.:«';�,. • . ,�;±, 9"r .,y, ia 5 4,.K.i. lag 24 16 05:26a Russell Welling Drilling 8286322617 p.1 Print Form WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: 1.Well Contractor Information: Chris Russell 14.WATER(ONES FROM TO DESCRIVrION Well Contractor Name 40 IL 485 3245A fr. D. NC Well Contractor Certification Number IS.OUTER CASING(for multi-aped wdh)Oil LINER(if a limbic) Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL Company Name 0 Ft 93 ft- 6.25 'm SDR21 PVC WELL-06-2016-073805 16.LINER CASING OR TUBING(geothermal dosed-loop) 2.Well Construction Permit#: FROM To DIAMETER THICKNESS I MATERIAL Lit all applicable well comtructioa /C,Court Stare.Variance,etc.) FL It. in. nn ti pennies(i.e.(ie. y, 3.Well Use(check well use): R. ft, iv_ Well: 17.SCREEN Water Supply FROM TO DIAMETER SLOT SITE. THICKNESS MATERIAL Agricultural ©Municipal/Public ft. It. in. Geothermal(Fieating'Cwling Supply) ©Residential Water Supply(single) IL ft. in. Industrial/Commercial ©Residential Water Supply(shared) la.GROUT Irrigation FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 R. 20 R Monitoring 0 Recovery R. It. Injection Well: ft. ft. Aquifer Recharge ©Groundwater Rernediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery ©salinity Barrier FROM TO ' MATERIAL I EMPLACEMENT METHOD Aquifer Test DStorrnwater Drainage ft. ft. Experimental Technology DSubsidence Conaot ft. It. Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach ode itlnasl sheets it accessary) PROM TO REECE/EITON(color,Iardanx sonrotk type grain sin.cu.) Geothermal(HeatingiCooling Return) nether(explain under N21 Remarks) 0 R 87 rt' Dirt 4.Date Well(s)Completed:8-20-16 Well IDn 87 iL 485 ft' Rock ftR. S.Well Location: Marilyn McCaslin AHP fr. ft. Faciiitviowncr Name Facility TIM(if opplcahk) ft. ft. 3652 N Olivers Cross Rd Newton NC 28658 It. ft. Physical Address,City,and Zip to. ft. Catawba 21.REMARKS County Parcel Identification No.(PIN) Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one Ist/long is sufficient) 22.Certification: 35' 35.683' 081' 07.619' 08/24/2016 6.lt(are)the wellas) Permanexat or DTempurary W �ature of Cetifie WeRC Contractor Date Ry signing this foram r hereby certify that the sell(n tens-(were)constructed in accordance 7.Is this a repair to an existing well: DYes or DNo with 15.1 NC4C 02C AI00 or ISA NERC 02C.0200 Well Cansvvaion Standards and that a If Noir is a repair,fill our.bioan well c astracrion information and explain the nature afthe COPi l this record has been provided to she wdf owner. fir oder#21 remarks-erection or arttire react of this Ions. 23.Site diagram or additional well details: S.For Genprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well construction d construction,only! GW-I is needed. Indicate TOTAL NUMBER of wellsdetails. You may also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 485 (ft.) 24, For All Wells: Submit this form within 30 days of completion of well For multiple wells lire all depths indifferent(trample-3@200'and 2@l00) construction to the foilowing 10.Static water level below lop of casing:40 (IL) Division of Water Resources,Information Processing Unit, If water level is above coning.use"+" 1617 Mail Service Center,Raleigh.NC 27699-1617 11.Borehole diameter: 6.25 (fa) 246. Far loiection 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: jr.,I. 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(gpm) 4 _ Method of test-_ Air 24c, For Water Sootily & Infection 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 1/3 cup completion of well construction to the county health department of the county where constructed. Font GW-I North Carolina Detainment ofEnvironmental Quality-Division of Water Resourcce Revived 2-22-2016