HomeMy WebLinkAboutWELL-04-2022-170076.TIF • .
ti- C CATAWR,Ar'U1'%TY
"�j Public liv3ltn[kj�,rt' ni N,.'wtn,.„n AVALON POINT
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Site Address: 9176 GREENWOOD RD TERRELL NC 28682
Name on Permit: 'IQ CUSTOM CONSTRUCTION INC
Property Size: AUes 3
Directions; Take right off of E NC 150 Hwy onto Greenwood Rd Property is located on a provate dry('located on left
before road turns into Gordon St
(hlner/Authorved Representatile Acknowledgement of Permit Receipt
I ee'rnt) that I.un the ooncr or authorrcit 44:nt tit,%ner.,,ruthorli.tuan re umrrdI retacwiltinr;the,..%tier„t
lb
the property des:rihed ahtnc
As the properly (,ssner or au4urrizcd representative. I ha%c rcrcised time abuse relcrenced
pernit(s)as requested in the application tor Net%ice KI4PK-03 2t122-40287,h. the ftllos►ing methudts►:
Received in Person
I•ac'nuile Transmittal tReturn form ssith signature required)
JElectronic linage'Iransntittal E-mail (Return receipt requiredi
As the pruper1s OM,net ttr authori/ed representative 1 hate Icsressed and undctst:1nd the specific urndititms
of the permit issued, and further understand that all applicable regulatory requirements specified under the
North Carolinw t,a is and Rules for Sewage Treatment and Disposal ti}stems(I 5A NiCAC I SA.14I41).
and/or Well Construction Standards(ISA NC AC 2C .010U). .hall apply In the rssuanee of %ltls permit and
the construction tit the tsastcssater s}+tent and or scaler supply ;sell permitted.
Permit Issue Date:04125Q022 •
(Nava Aulhnriied 1Zeprc.errluti%e Signature /Wee(
l):rte61(Di elm
Documentation of Permits) Iransmiital
(permit transmitted by electronic or other means)
Pei hill transmitted hk 0none tit per'.soNl.ierrilNl,l;perotlf.1
Signature Date Lime 51 1 13)
%lethrttl: Fas J _Entail _ VS Mail -Other
Owner's request to send by the abuse indicated method of transmittal in lieu of signature
We wane tto hear from yo&Please hake a few momentts tto complette our custtomer service survey an
http://www.surveymonkey.corn/s/EI4CusttomerService
1 bt 1A.5611 I add,_# 30,A,t. teen
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WELL CONSTRUCTION RECORD)f(W:[) Por Internal Use Only: •
• 1.Well Contractor Info�rmattiioyn:
j6Umi'l
C Xv • 4•:.WAT '✓o .a..l: :WXr`�`�r'•1.1,:4:'::::44"cif 4dt w•.t,n..:..4� t .Well Comica FROM f)' ` i:' "1l;'zi
TO DESCRIPTION
_OS ft .ft. v
- `-��—'�'` ft ft.
NC Well Contractor Certification1lumber •
11•SJ.OME. 41040 144g(idaieltWiti:(Zl'j;2LVORX. it•OCMgli tli.r0:C1iYrt4;Sy:(Si•'.
Morgan Well&Pump, INC • FROM TO DIAMETER TBICRts$S MATERIAL •
CompnhyPlema 0 ft 51. it '61/a hi' sdr-21 pvC
►� �.. n4� .`Itito1 iNa.pgccovi *rklit 4lnr k4a -ieap}'•i':.•.i`t:t'•J 401-.4.);r;'•6'i Ji
2.WellConsfrucflonPermff#: �,� �,��� PROM • TO ' DXAMBTER ' THtCEMSs MATERIAL .
Listalkappltcable well constnrotionpens Is(1.e.'We,Catarty,State,Variance,eta,) ft. ft. In.
' 3.Well Use(checicwelluse): f: ft I in,
Waal'BuplyWell: iRO •':4•:.:.v•V a:: 5s•.trti'.71.'i `,e.:«i:':::arfY:ii 'i.,'v ..:.
l{:
Fl17
• Agricultural TO DIAMETER sLOTSIZE TRrCIO1ESS idATERTAL
0Municipai/Publia ft. ft. in.
Geothermal(Heating/Cooling Supply) wResidentlal Water Supply(single) ft, it: in. .
Industrial/Commercial • �ResIdential Water Supply(shared) •
Irrigation O y,•.r. a or. ,,, •
,r. 1-,::t r!,,•ICt?•G-'w• t..;*. r r••':,r,L:'+:a.•• .
TO MATERIAL EIIIPLACBMENTMETHOD&AMOUNT
Non-Water Supply Wen: o ft• Z0 f
tm bentanite poured
Monitoring Injection Well: �RecoVery ff ft. r
Aquifer Rechar a t�l� ft. ft: '
g ClroundwaterRemediatian 119: GRb.'(rFLI.A. (C ap )'3 rteable r.: ••
Aquifer Storage andReaavery a Salinity Barrier FROM TO MATERIAL r: ACSIKE-,:
NTrlt$THOD 4
AgnlferTest laStormwaterDrainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) jJjTacer •20:JDkIPWCxVairdrtdcFcnddSdSfi3T'aHedts?Cne bs r'�'":. ::k9.. :
Geothermal(Heating/Cooling Return) + Other(explain under#2IRemar•Irs) FROM TO nF+*S-C�R�tI'T►ON(color,Bardnas,sat]/rockiypggtninalseetr)
4.)Date Wells)Completed: kb l is !)-SWelllD# • ft � —1 YQ��h�
5a.Well Location:
t � 3° J'jYt7kotea cot
�
e 1 u tab. ze vos r-r� g ram,--e,
PAO1I1y/ wner'Name Facility Dt(if applicable) ft: K'' •
gtii • 124161d .Tzgrr.1,L Nc.aig(d — ft ft,
Phhysiicctity-(all Address,City,andZIp ft. ir.
Idt 1110A' rt $)a'a.' i`.1FMen:' `r:::::i:'t•DX:"0053+a;e0..041g•3'a,,.v: :: IL%lit>;)::•
County ParceIldentlfication No.(PIN)
5b.Latitude and longitudein.degrees/minutes/seconds or decimal degrees:
(ifwoll field,one Int/long Is suffiotont) 22 cation:
35.575 N <1.0.q+-V35 W •
ibp-6 (a-s
6,Nara)the walks)r?ermanent or I3Temporary SI edWe Contractor Data
ng his onn,I hereby certify that the wells)yen(were)constructed in accordance
7.Is this a repair to an existing well: CEIYes or rinNo with MN C d2C.0100 or 13A MAC 02C.0200 Wall Construction Standards and that a
Ifrhfstsa repair,fill out loom well construction informalien and etplain the nation ofthe copy ofthis record liar beasprovided to The Well owz,er. .
•'repah'under#21 remarks section or on the back ofthisfora• 23.Site diagram or additional well details:
8.Nor Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of kids page to provide additional well site details or well
construction,only OW-1 is needed.Indicate TOTALNIIMBERofwells construction details.You may also attach additionalpagesifnecessary.
drilled;•t ,S"IIBIVL(TTAL INSTRUCTIONS •
) r
9.Total well depth below land surface: �b t-7. (ft-) 24a.x'or All Walls: Submit this form within 30 days of completion of well . t For mul!lplewells list all depths ifdiferent(ezornpie-3@200'ard2Q100') constmotlonfofhe.followIng t
10.Static water level below top of casing: 3b (ft;) Division of Water Resources,Informatfonpxoceasfn Unit
Nafar Wei is above easing,usa"•t' 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: 6 'US (In) 24b.per Infection Wells: In addition to sending The form to the address in 24a .
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(La.auger,rotary,cable,direotpush,eta)
Division of Water Resources,Underground Injection Control Program,
NOR WArnatSU1I'LY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC276991636
13a.Yield(gpm) t Method of test:air 24c.):tor Water Snpoly&Infection 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:Granulated ei}lodna Amount: GM) completion of well construction to the county health.department of the county I.
where constructed.
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Form OW-I 'North Carolina Department ofB wironmentaL QuaUty-bivision of WatarItesources Revised2-22-2016