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HomeMy WebLinkAboutWELL-07-2016-074591.TIF • gA CATAWBA COUNTY Case# 2,T �t Public Health Department Subdivision < Environmental Health Division PINI/ 269801274107 tPO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOT# 44/6 NAME ON PERMIT: TERRY LIDEY, 3719 RHONEY FARM RD, VALE, NC 28168 Site Address: 6021 W NC 10 HWY, HICKORY NC 28602 Property Size: Square Feet:229,561.20 Acres:5.27 Directions: Hwy 10 W, just past Plateau Rd, property on left Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that lam the owner or authorized agent(owner's authorization required) representing the owner of the property described above. A^/As the pro erty owner or authorized representative, I have received the above referenced permit(s) as requested in t e application for service RBPR-06-2016-24094 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 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: 07/15/2016 �� r �////// Owner/Authorized Representative Signature it Date lc\Ci\\(..f Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name o/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 ni it 07/15/2016 09:15 `,33A CATAWBA COUNTY 0 'o -s 0 CaSe 6 WELL-07-2016-074591• •p G Public Health Department 7 { Th4 Suhdivision �• ?. �3.. 269801274107 1119 Environmental Health Division 1 ' 1 INk o• ti•rr- � PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 {{Gyr � � ��{O � LOT# orr flan . ..o • NAME ON PERMIT: TERRY LIDEY, 3719 RHONEY FARM RD, VALE, NC 28168 Site Address: 6021 W NC 10 HWY, HICKORY NC 28602 Property Size: Square Feet: 229,561.20 Acres:5.27 Directions: Hwy 10 W, just past Plateau Rd, property on left 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 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. Megen McBride 07/15/2016 AUTHORIZED STATE AGENT APPROVAL DATE chpermit 07/15/2016 09:07 If, AG, VUaL 1) :-Oh-JO jo-7` o9L (0).1 w tvG I (-flvj. t1iick,or-y * ins-14 Ions 0y, _rrt��041 Se?fcc. cank- nr4 300-f of 52,; Rea,/,{-,‘0,, , Lf 5,ff_ ii,,,1Cb'. f v,sAtall .cArcoi'metck Ctrs- (Or +O( pT L s-,Isite m F' t 't Le, )00-11 -From i IfkiF"_'[K X5 1. -t Ci U- } -. •i ,N ∎ i ,- . I nCktinei - = anti. Poccke;, I0-0. r;rn prwp2r+ ;,F�Pc -f ' - , ," !! ,, ,,, and o e, r.-t.,! ,;40.,, Li;'0, E ..p,.,, _ ;�;., x QJ i!p ari Qe1 a`Se,aZl CU , 0( r ill G4lei ((2 _ C, 0lete;s. ' t 'v 'y' A 1 a 11 02 r (r 0 f septicRep�.irAkc( 1 ash, R duc iorq f L ?5,Lio i i I a5' I I * 1f\1e1� pus!' lot, 011 ieo ° i it - (00 f�'. crofa . i (- t', s-i-e ms n- x' lip. 1 pro P osea 3 Eh - )-51-,1 L r< S rc��� e c inU vd9 r •5s I ro ,iar Ix30 < j !if 35 I i pord1e3, 1kf iJ c, -.1 - 7 bxb PhaGy I I 1 1 G (; . - (1 p°, p(}4' il hnes IOU Garag2 at{xxN I 1 <CCI) Vi G DUc 0, : ria4ti'•�-ir-�: -z S o_3 , 2 zo`i l -6 a I w e+ ' Nrea -eI i -� of i i ; t. i --— n l ptS, ,, , I r I v 1 V B . 18 16 08:29p 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 ZONES Well Contractor Name mom TO D£6CRfPT10N 3245A 20 ft 265 It. ft. ft. NC Well Contractor Ca4Latinu Number 15.OUTERCASING(for multi-eased wells)OR LINER Map flyable) Russell Well Drilling, Inc. FROM TO DIAMETER THIICK:NESS MATERIA. Company Name 0 ". 80 "' 6.25 '°- SDR21 PVC WELL-07-2016-074591 16.INNER CASING OR TUBING(geothermal dosed-loop) 2.Well Construction Permit It: FROM TO DIAMETER TRICENESS MATERIAL Lice all applicable well construction permru(.e.C//C,County,State, Variance,vee) ft. ft. in. 3.Well Use(check well use): ft. a in. Water Supply Well: 17.SCREEN FROM TO DIAMETER ' SLOT SIZE I THICKNESS MATERIAL Agricultural OMuoicipallPublic n. H- kb Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) n. ft in. .• IndrsstrieVCmnmercial DResidcmdal Water Supply(shared) 18. GROUT Irrigation FROM TO MATERIAL I EMPLACEMENT MF.-fHOD6 AMOUNT Non-Water Supply Well: 0 ft- 20 D- Grout I Poured Monitoring DRecovery f. R. Injection Well: ,' ft. It : Aquifer Recharge Ocmundwatcr Au-mediation I I 19.SAND/GRA VEL PACK(if appticahlc) Aquifer Stern Pe and Recovery DSalmtty Ramer FROM TO MATERIAL. FNPLACEMG-r METHOD Aqui for Tear DSmrmwater Drainage ft. n. Experimental Technology ©Subsidence Control R. ft. Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach addidaml sheets if necessary) _ Remelts)Geothermal(Hcatine/Cooling Return) DOther(explain under#21 FROM I CO DF'SCRlV ION dolor,aardaas,oil/md.type,pale axe,de) 0 tt 175 1t Dirt 4.Date We6(s)Completed: 08/17/16 Well ID# 75 265 f° Rock Sa.Well Location: ft. ft. Terry Lidey-Clayton ft ft- • Fteitily/Owner Nance Facility 1171/(inapplicable) ft. ft. 6021 W NC 10 Hwy Hickory NC 28602 ft ft. Physical Address,City,and Zip R- H. Catawba 21.REMARKS County Parcel Id=afcation No.(PIN) 5b-Latitude and longitude in degreesirtdnutes/seeonds or decimal degrees: (if well Lela one tat/berg it sufficient) 22.Certificate,.. 35' 45-204' , 81' 04.291' Wl. • _ -„a � . �� 08/18/2016 6.Is(are)thewell(s)OKPermanent or OlTemporary gnat, of Certified Well Geometer Date By signing this form,I hereby car t'that the walk'')nv..(were)con-carted in accordance 7-Is this a repair to an existing well: OYes or ED No with 15.4 NCAC 0X.0105 or IsA,NCAC 02C.0200Wed Contraction Standardr and that a 11 this is a rrpaic VII!nut blown or!I construction information and explain the ventre of the copy'Nu record has been provided to roe art/owner. fir under On remarks section neon the hock of Ono form 23.Site diagram or additional well details: B.For Geoprabe/OPT or Closed-Loop Geothermal Wells having the sante You may ane the back of this page w provide additional well site details or well construction,only I OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoartuch additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 265 fL ( ) 24a. For All Wells: Submit this font within 30 days of completion of well For multiple wells list all depth if Waren(cantle-3@206.and 2CI00') construction to the following 10.Static venter level below top of casing:20 (ft) Division of Water Resources,Information Processing Unit, If water level is above easing,use"4" 1617 Mail Semite Center,Raleigh,NC 27699-161 7 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: (i.e.auger,rotary.cable,direct push,[rte.) construction to the following: Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 2 7699-1 63 6 13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13R Disinfection type: HTH Amount: 2/3 cuD completion of well construction to the county health department of the county where constructed. Foam GW-1 North Carolina Department of Environmental Quality-Division of W ate/Resuurcm Revised 2-22-2016