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Home My WebLink AboutWELL-09-2016-076681.TIF ,gA CATAWBA COUNTY Case# 4 .,C: 1:31 tz, Public Health Department Subdivision Wig: 14 Environmental Health Division PIN# 368804746467 '-t`- `PO Box 389. 100-A Southwest Blvd, Newton, NC 28658 LOT# 3 l8,'}. SM, NAME ON PERMIT: PAUL NELSON, 2865 MATHIS CHURCH RD, CATAWBA NC 28609 Site Address: 2853 MATHIS CHURCH RD, CATAWBA NC 28609 Property Size: Square Feet:257,396.04 Acres:5.909 Directions: HWY 16 S LEFT ON BUFFALO SHOALS RD RIGHT ON LITTLE MOUNTAIN RD LEFT ON MATHIS CHURCH RD BESIDE 2850 MATHIS CHURCH RD ON LEFT SIDE Owner/Authorized Representative Acknowledgement of Permit Receipt ejt_ I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the erty described above. As the property owner or authorized representative, I have received the above referenced permit(s) as ...Q___ requested in the application for service RBPR-08-2016-24511 by the following method(s): JReceived 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 ftPi 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: 09/12/2016 Owner/Author.zed Representative Signature / / tate Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of 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 chperm it 09/12/2016 09:19 ,y,ACATAPBA COUNTY Oe e Case# WELL-09-2016-076681 4 �•y Public Health Department ` •J.JF Subdivision Y Environmental Health Division t' •" • a`S • PIN# 368804746467 Lir*" PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 Cir LOT# 3 1842 w 0� 1•Gr;{.0 NAME ON PERMIT: PAUL NELSON, 2865 MATHIS CHURCH RD, CATAWBA NC 28609 Site Address: 2853 MATHIS CHURCH RD, CATAWBA NC 28609 Property Size: Square Feet:257,396.04 Acres:5.909 Directions: HWY 16 S LEFT ON BUFFALO SHOALS RD RIGHT ON LITTLE MOUNTAIN RD LEFT ON MATHIS CHURCH RD BESIDE 2850 MATHIS CHURCH RD ON LEFT SIDE WELL PERMIT 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 09/12/2016 AUTHORIZED STATE AGENT APPROVAL DATE elipermit 09/12/2016 09:21 �''p G CATAWBA COUNTY Permit# RBPR-8-16-24511 zn�,�ue 2 Public Health Department Name Paul Nelson Q 1 "� Environmental Health Division Address 2853 Mathis Church Rd Catawba ""rv. 4hGv PO Box 389, 100A Southwest Blvd,Newton NC 28658 NC /842 s,,, (828)465-8270 Fax (828)465-8276 TDD(828)165-8200 PIN# 368804746467 Site Plan Authorization to Construct 10 °/ nsi 12s/" • An... a S 9 o a°-� - rr to' nr`F.rra. t �f�fl �y owr, ..r 1 2. p.ol ri (/as • ! 116-.'"F 2.S' w 2 0 I I 1$ 1 a. 3 ,` 3B24, T K. lei St: ri 7 7s. r ` rv' _nt`J \61)73—/ or o T J 7V ( 5o - q4 ' /3-2 '7S-DY /1/1 + 1 „ 3 C L .., rC-k, 4 ) 11° LoT („) /`c J._d prto /` I- o 2v c/�I ' c14' • I II r Scale - ' 6 0 /1., s k Li._ Q_x }- ni o. a -(-b 3 i./../...r± w re lc” c•,to y Pro ,.-, S V s+--^-\ • ep 15 16 02:52p Morgan Well& Pump, Inc. 7049330455 p.1 • • WELL L CONSTRUCUO1V RECORD(GW-1) For IntemaI Use Only: • 1.Well Contractor Information: •' Chris Morgan 14.WATER ZONES Well Conlrocior Name FROM TO DESCRIPTION — 3572 ft. ft. NC Well Contractor Certification Numb= ft. R. Morgan Well& Pump, Inc. 15.OUTER CASING(for multi-eased wells)OR LINER(flap licable) FROM TO ! DIAMETER I THIcnaitss MATERIAL Company Name +t R• I i2....? it. FL 6 118 in- I sd27 (� t 2.Well Construction Permit 4: � P1` —142-L(K i ( 16.INNER CASING OR TUBING(geothermal closed400p) FROM TO DIAMETER THICKNESS l >;iATERIAt.. List iliapplicable well construction permits(/,a U/C•Canary,State. Variance,arc.) ft. IL 1 in. 3.Well Use(checkwell use): ft. fL in. Water Supply Well: Agricultural t/.SCREEN TO DIAMETER SLOT SIZE MATERIAL Geothermal(Heating/Cooling ft. Supply) R. [Q in. g Su PP)) Residential Water Supply(single) Ri, I R. ft, in. :Residential Water Supply(shared) Irrigation IS_GROUT Non-Water Supply Well: FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT o R• 20 ft. bentonite poured [DM on Monitoring ORccovcry Injection Well: ft. fit. OAquifer Recharge OGraundwaterRcmediation ft' ft. OlAquifer Storage and Recovery OlSalinity Bather 19.SANDiGRAVEL PACK(it-applicable) 0 FROM TO MATERIAL F.MPIACEMENT METHOD Aquifer Test OStormwaterDrainage ft. n, Experimental Technology OlSubsidence Control ft. n. Geothermal(Closed Loop) OlTracer 2D.DRILLING LOG(attach additional sheets if necessary) A Geothermal(Heating/Cooling Return) Other(explain under tf21 Remarks) FROM To DESCRIPTION(mlur.hnrEnoR sail/rack type;Frain she•etc.) ■ f• SC) it. �t rjl• e 4.Date Well(s)Completed: i J GJ i, tr v 1 t 1 t� Well um nla �j(O ft. xs fl. Sa.Well Location: " v/? y�C CI'V a f ft. 'v° IY. SON- tpro.1.)� `'bile T k il P.-L500 n/a k 24) ft. 3qo ft. Ewe- 104n LAG Faciliy/Owner Name Facility MO(if applicable) ft• ft. g 1 I63 YY\ojtn lc Ii u ed "i`'1,2 NC ft_ ft_ Yl cPhysical Add .lC3UJ JI and Zip ft. ft. _.yn� _ n/2 21.REMARKS County Parcel Identification No_(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • (if it'd;field.one tabloag is sufficient) 5 22.Certification: v to l 3 l V ,0 5q-n( W .6.Is(are)the wells) X perm ur OTemporary J / __ Dale I /S 1 l Signature e.t•CcrtiC7Ed Well Contractor Dale 7.Is this a repair to an existing well: OYes or �No By signing"his form,r,1 hereby cerrh•that the n•efl(c)war(were)constructed in accordance .rJrh 154 NCAC 02C.0100 n.154 NCAC 02C.0200 Wert Cnn ctrvatina Biondardr nod rimy a ifrhfs is a repair,fill oat known well construction information and eapiain the nature oldie copy of this record has been provided to the well(Mner. repair ander 1`21 remar/s.rectiion or on the back of this form. 23.Site diagram or additional well details: S.For Ceoprobe/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: � r Jh SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: tU Formnhipie wells7isra(idepths fd creel(erarnple 30200"and @/t703 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well 10.Static water level below top of casing: �J-��(0 construction to the following: 10.Static level is above casing,ose o+ (R) Division of Water Resources,Information Processing Unit, 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6 (in.) 24h.For injection Wells: In addition to sending the form to the address in 242 12.Wcti oonstructfon method: rotary above, also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary,cable,direct push,etc.) construction to the following: Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 6 Method of test: air pressure 24c.For Water Supply&Injection Wells: ht addition to sending the form to granular 13b.Disinfection lar �( the address(es) above, also submit one copy of this form within 30 days of type: Amount: l l•OZ. 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