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CATAWBA COUNTY Case # WELL-2-10-4785
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2 Public Health Department Subdivision
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Environmental Health Division I/Ph/Lot#
PIN# 36361 1552444
PO Box 389, 100A Southwest Blvd, Newton NC 28658
1$ Z Ski (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200
Applicant/Owner Michael Drum
Site Address: 604 Salem Church Rd
Property Size: 134
Directions:
WELL PERMIT
Proposed use: Private ® Public ❑ Semi-Public ❑ Other
GROUTING DEPTH: MINIMUM 20 FEET
SETBACKS:
1. BUILDING FOUNDATIONS 25 FT. 5. UNDERGROUND STORAGE TANKS 100 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT. 6. STREAMS/BROOKS/CREEKS 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 7. LAKES/PONDS RESERVOIRS 50 FT
4. SEWAGE PUMP SUPPLY LINE 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all separations are adhered to before drilling the well.
If the well driller is unable to maintain any of the above separations, contact the Health Department at (828) 465-8270 before drilling the well.
SEE SITE PLAN FOR PERMITTED WELL LOCATION
Luke Sears REHS 2/17/2010
ISSUED BY PERMIT ISSUANCE DATE
CUSTOMER SIGNATURE DATE
WELL INSPECTION:
GROUTED DEPTH: 20' ❑ DATE: I Z f D INITIALS:
APPROVED CASING: PVC ❑ STEEL ❑ DATE: - - v INITIALS:
CASING HEIGHT 12' ABOVE LAND SURFACE ❑ DATE: - INITIALS:
WELL COMPLETION REPORT RECEIVED ❑ DATE: INITIALS:
WELL HEAD APPROVED ❑ DATE: INITIALS:
WATER SAMPLES TAKEN: BA ❑ IO ❑ N/N ❑ DATE: INITIALS:
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WE L IL ER DATE DRILLED
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation for non-compliance with
appropriate state and local rules and regulations, or if false information was given in order to obtain a permit. Wells shall be constructed in
accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department within 30
days upon completion of a well.
CERTIFICATE OF COMPLETION
AUTHORIZED STATE AGENT APPROVAL DATE
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