HomeMy WebLinkAboutWELL-07-2016-074792.TIF �6A CATAWBA COUNTY Case# _- - _,
�.�. s 'j Public Health Department Subdivision WYNSWEPT PH 1
Q =,. Environmental Health Division PIN# 367804517494
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' PO Box 389, 100-A Southwest Blvd,Newton. NC 28658 LOT# 29
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NAME ON PERMIT: *BEASON GENERAL CONTRACTORS, PO BOX 636, SHERRILLS FORD NC
28673-
Site Address: 4564 CAYTON DR, MAIDEN NC 28650
Property Size: Square Feet: 34,848.00 Acres:0.8
Directions: take hwy 10 to hwy 16 South and turn left onto Cayton Drive, Property is .3 miles on the left
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
property described above.
v As the property owner or authorized representative, I have received the above referenced permit(s) as
r requested in the application for service RBPR-03-2016-23539 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: 04/08/2016
` Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitxed b, , pA�Ii a S (name of person se ding permit
Signature �j� AIS ` I °1 r 4 Date/Time i i Co 0 I I t IS
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:
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ehpennit 04/08/2016 12:07 Page 3 of 3
�pA CATAWBA COUNTY �e �' f E Case# WELL-07-2016-074792
�G Public Health Department r '11� Subdivision WYNSWEPT PH 1
i r '� r••
4 r t 14Environmental Health Division ti �r ' • PIN# 367804517494
� PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 ' � Liejr' LOTlt 29
El . To
NAME ON PERMIT: *BEASON GENERAL CONTRACTORS, PO BOX 636, SHERRILLS FORD NC
28673-
Site Address: 4564 CAYTON DR, MAIDEN NC 28650
Property Size: Square Feet: 34,848.00 Acres:0.8
Directions: take hwy 10 to hwy 16 South and turn left onto Cayton Drive, Property is .3 miles on the 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.
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 welt
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 I 8A .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 04/08/2016
AUTHORIZED STATE AGENT APPROVAL DATE
ehpennit 07/20/2016 12:40
��3A Permit ' I RBPR 3-16-23539
�` �. CATAWBA COUNTY Name _ Beason General Contractors
L+",�" , Z Public Health Department AddressI 4564 Cayton Drive Maiden NC
4 r '? ; Environmental Health Division
/-66, PO Box 389. 100A Southwest Blvd, Newton NC 25658 PINIh 367504517494
842 5,, (828)465-8270 Fa (828)465-8270 TDD(828).165-8200 Lot 29
Site Plan Authorization to Construct
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Aug 22 16 10:27a Advanced Well Drilling, L 8282412445 p.2
WELL CONSTRUCTION RECORD For Intermit Use ONLY:
This form can be used for single or multiple•setts
1.Well Contractor Information:
Michael y� 14.WATER Z01C cc. - •I
iviJ-Ct iaei {I V. Shaw FROM ' TO / DESCRIYTTON'
Wei ContractorNxine 1 2...Oft 9�b't.
3232 ( fr. [ It,
NC Well Contractor Ceniticafian Number IS.OCTTR CASfNG(krinulrf-eased t�'d1s)OR 1,MER(ffaepUcutile) .
FROM DIAMETER THICKNESS MATERIAL
Advanced Well Drilling, LLC b f4 LTO 7 tt. ,6 itL Heavy PVC
Company Name I&INNER CASING OR TUBING(geothantisl closed loop)
f `/ FROM TO ( DIAMETER THICKNESS MATERIAL I
2.Well Construction Permit 44J 1 '6 12011 -6T el 7?a R. ft. 1 in. I
c 1
List all applicable tell rorutnrtionpernits fix.County,Sae.Variance.el.) It. ! f[. In.
3.Well Use(check well use): 77.SCREEN ...:. • • •
' FRO.lt ' TO DdnitiLTEE ' star size: t ronero'eSS r a/ATER/AL
Water Supply Well:
fi. It hr.
CAgricultural DMunicipal/Public r
ft ft. ' in•
DGeotbermat(Heating/Cooling Supply) EResidential Water Supply(single)
DlndusttiaUConsme eial R.e identia.Water Supply(shared) 1/1.
GROUT
FROM TO MATERIAL _--. EIWLACEME.NT METHOD&-AMOTINT
°irrigation /''1 11. .20 rL Bentonite Poured
Non-Water Supply Well: LJ ft. ft.
°Monitoritlg °Recovery
injection Well: ff. t 6L 1 l
°Aquifer Recharge °Groundwater Remediation :I9:SAID:GRAVELP:ACK(If apPUcabte)..1• • • • • • .
FROM 1 TO l ,IsrATERrAt. F.MPLACL%iEHT I IETILOD
GAquifer Storage and Recovery °Salinity Barrier ft; ft.
°Aquifer Test OStotmwaterDrainage It. tt
0Experimental7echnolo ❑Subsidence Control -:20:DRILLING LOG(a nacre udditiooal sheet'ifnecessary) .
DGeothermal(Closed Loop) :Tracer , FROM TO DESCRIPTION(rotor,hardness.aott/rxk type.grain size.sec.)
°Geothermal(H eating/Cooling Return) DOther(explain under#21 Remarks) 1) ft. �j7 f ,p,11�`
4.Dote Well(s)Completed:7 Z Z—1Z Well 97 " iO rl ft J"f
Sal/Well Location: 601,,-,./(;..172., n. fa
l L2,��i it. , tr.
Facility IDx(if Far;htyrotrner N y (' applicable) i Et. ft.
;72/_,-_,4
Li 0 c t2 Te,, Pr , G ft. ft.
Physical •City, n dip ��r 21:REMARKS•�� �4 ,7/ n[j l j, 111. /
County Farcel�nriCca!ion No.(PIN)
5b.Latitude and Longitude in degreeslminuteslseconds or decimal degrees: 22.cert. align:
(if well field,one tat/tong a sufficient)
`- s
/
- D.`°5--727.Y ,
�4
Signature of Certified Well Contractor Daze
)]]''__s S( J
wel(s)c ga Permanent or OTemporary Cy signing nits fern!, 1/torebr cerriji,fh:A the ttrt1/(y was(were/consrrtraed in accordance
uirh 15.i NCAC 02C.0100 or I5A NCAC 02C.0200 Well Canstructin,r Standards and that a
7.Is this a repair to an existing well: ❑;des or copy,!(fills re-ordhmi been provided to the well n»ne•,
If Mir is a repair,fill out Mulct well romn'rtctlon information and ecplain the nature of.the Site diagram or additional well details:
repair tender 1/21, narks srdisn or an she hack of Mist's/on. n S
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For null tiple infection:or non-outer supply IIT!ti ONL Y:with the same ecnsatrtalou,you can
submit one form. � �J SUBMITTAL INSTUCTIONS
/ ,
9.Total well depth below land surface:, `� 0 r/ (ft) 24a.. For All Wells: Submit this form within 30 days of completion of well
For multiple irr/Lc list all depths ifd crept(example-343:200'and 2(81001 construction to the following:
10.Static water level below lop of casing: Li L/ (ft.) Division of Water Quality,Information Processing Unit,
If wirer level in oeove casing,ose°T.• 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) n 246.For Infection\Veils: In addition to sending the form to the address in 24a
( �`,,- . above, also submi:a copy of this form within 3D days of completion of well
12.Well construction method: 410, U construction.to the following:
■Le_auger,rocsry,eslt''..direct vst etc.
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY_WELLS ONLY: 1636 Mail•Service Center,Raleigh,NC 27699-1636
1yJ Method of test; Air 24e.For Witter Sunnh-&.Tniection Wells: in addition to sending the form to
132.Yield(gnu) the addresses) above, also subunit one copy of this form within 30 days of
1-4TH �lmouw■• / completion of well construction to the county health department of the county
tab.DisnttccHOn type: / — where construceal.
Form G W-I North Carolina Department a/Env imntncar.and Natural Resources-Division of Water Qualify Rescued Jan.2013