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Home My WebLink AboutWELL-08-2016-076068.TIF r.\-)v ,r) CATAWBA COUNTY Case# WELL-08-2016-076068 f _ Public Health Department Subdivision G d Em:ironmental Health Division PIN# 361812756216 1�F, 'il PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOT# Ig.2 �, NAME ON PERMIT: XIA VUE, 3630 ROCKY FORD RD, NEWTON NC 28658 Site Address: 3630 ROCKY FORD RD, NEWTON NC 28658 Property Size: Square Feet: 212,137.20 Acres:4.870 Directions: W NC 10, left Hickory Lincolnton Rd, left Rocky Ford Rd, approx 1/2 mile lot on left Owner/Authorized Representative Acknowledgement of Permit Receipt 1 V1 certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in he application for service EHPR-08-2016-24551by 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: 08/24/2016 Owner/Authorized Representative Signature /` tC-- 0?�z...---- Date slo)5/14., 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/EHCustomerService elm/A-mit 08/24/2016 08:54 sA CATAWBA COUNTY � ' �G0'� Case# WELL-08-2016-076068 .7 1-4111 7, Public Health Department • ry; � {1�' Subdivision k113 7 119 ��I H Environmental Health Division • PINK 361812756216 �� PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 •12 �3 i r LOTS /Hq2 sr •• �� A ? ra. a i. i ■ NAME ON PERMIT: XIA VUE, 3630 ROCKY FORD RD, NEWTON NC 28658 Site Address: 3630 ROCKY FORD RD, NEWTON NC 28658 Property Size: Square Feet: 212,137.20 Acres:4.870 Directions: W NC 10, left Hickory Lincolnton Rd, left Rocky Ford Rd, approx 1/2 mile lot 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. 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 08/24/2016 AUTHORIZED STATE AGENT APPROVAL DATE chpennh 08/24/2016 08:54 EHPR 08-2016-24551 3630 Rocky Ford Rd,Newton • 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. I t° rwr 3u 0 ®_° `LW t.-u reA ‘.ay' ti cl;' d ti� `‘A' loo Print Form r'. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Chad Hartness ,14..WATER-ZONES . ' . .- ' - '': ' FROM TO DESCRIPTION Well Contractor Name 0 ft. 580 ft. -0- 2901-A 580 ft- 605 ft. 80 GPM NC Well Contractor Certification Number `15.`OUTER'CASING'(for multi-cased wells)OR LINER(if ap'licable)-''- Hickory Well-Drilling Co., Inc. • FROM TO DIAMETER THICKNESS MATERIAL 0 ft- 35 ft 61/4 in' .185 �Galy.Steel Company Name 16.INNER CASING OR=TUBING eothermal c{osed-foo WELL-08-2016-076068 DIAMETER p' ' 2.''Well,Construction Permit#: • _ FROM TO DIAMETER THICKNESS MATERIAL list all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)- ft. ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agriculture) [Municipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) ''�!Residential Water Supply(single) ft. ft. in. Industrial/Commercial D Residential Water Supply(shared) ..IS.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT Non-Water Supply Well: 0 ft. 20 ft. Bentonite Poured Monitoring D Recovery ft. ft. Injection Well: ft. ft. Aquifer Recharge [Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)- - -- = Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test IStormwater Drainage ft. ft. Experimental Technology DISubsidence Control ft. ft. Geothermal(Closed Loop) Tracer 20.-DRILLING LOG(attach'additional`sheets if necessary) -.: Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain gig,etc.) 0 ft. 30 ft- Dirt and Loose Rock 4.Date Well(s)Completed:09/01/2016 Well ID# 30 ft- 605 ft. Granite Bed Rock ft. ft. 5a.Well Location: Xia Vue ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. . ft. "'(ECEIVED 3630-Rocky Ford Rd., Newton, N. C. 28658 , ft. ft. . Physical Address,City,and Zip ft. ft 5 E.N Y 6 1 0 1 Catawba 361812756216 21.REMARKS': . CAT V‘;6.4 COUNTY County Parcel Identification No.(PIN) (V I'-,'ON v'r NTAL HEALTH 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification' N35 36' 40.0" N W81 17' 45.9" w / - 09/13/2016 A:.. • 6.Is(are)the well(s){)Permanent or []Temporary Signature of Certified We'Contractor Date By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: II Yes orENo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: 8.For Geoprobe/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.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled:One SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 605 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple welds list all depths if different(example-3@200'and 2 @100) construction to the following: 10.Static water level below top of casing:106 (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter:6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a Rotary Air above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: construction to the following: (i.e.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)80 Method of test: By 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 13b.Disinfection type: Chi. Grans. Amount: 15 Ozs. (75%) completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016