HomeMy WebLinkAboutWELL-05-2022-172450.TIF 0= e CATAWBA COUNTY
./.l j Public Health Department
Sutulivision WYNSWEPT PH 3
Q(rmt, w PO, Environmental
389,25 HealthGovern DimventisionDrive,Newton, 58
NC 28658 PIN# 367804616494
LOT6
Site Address: 4618 NORTH WYNSWEPT DR, MAIDEN NC 28650
Name on Permit: 'MODLIN CONSTRUCTION, INC.
Property Size: Acres 0.76
Directions: Hwy 16 S towards Denver once pass Buffalo Sholas intersect Wynswept is on left Left at 1 st intersection Lot
58 is on the Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
'2 1 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
Fiermit(s)as requested in the application for service RBPR-01-2022-39790,by the following method(s):
Received in Person
_ Facsimile Transmittal (Return form with signature required)
_., Electronic Image Transmittal/E-mail (Return receipt required)
iAs the property owner or authorized representative I have reviewed and understand the specific conditions
6fthe 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: 05/27/2022 '
Owner/Authorized Representative Signature _ - =°' .-_.•
Date (9/i/4°4 Z".
1 j
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature _ _ ., _ Date/Time &b e,/.))
Method: Fax J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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.I:"..cnmi 05.'27;2022 16 19 V_ !
Pririt Form
,.........,,,„..A'F.LL CONSTRUCTION RECORI)(C11'-l1 For Internal Use Only:
1.Weil Contractor information:
Joseph Bailey 14,HATER L(1NE,t
Well cantrweee\sine FRisvl In rat:scRinto%
3271-A lSD R Jd_n'. �4�j` ✓2'�d�IG'
NC Well Conuactut C rnificatnn Numberr MITER R• 1! R' � �1 ils G�
I . TER CASING(for multi-e we 1 OR LINER Ora )
B&K Well Drilling inc FROM TTo -1. n u%iF.TER I THICKNESS MATERIAL
Company Manx 0 a OI R' I 6 tR In, SOR•lt PYC
LiIANECASINGORTLBING(feotbarmhltle
2.Well CbnstrucNonPttmlt4: /0c—)0 .. //7,`/5U TRusl To DI 01ETER I THICKNESS
T MArCRIAL
Lsra/:ga}daMe...aconstnu(WA r`er iit.,iie.I.A..('wrn . Isrran.e.et;
ft. , ft. in.
3.Well Use(check w ell use): rt. ft. in.
Water Supply Well: 17.SCREEN
❑ cultuMl L FRO>I _ TO DIAMEr'ER SLOT PILE THICKNESS —SLATE:RIM,
QMtu pal Public f, ft. Ia.
Geothermal(Heating Cooling Supply)g
csidrntial Water Supply(stnglel In.
hlmcation
R. I n. i
lndustrisj Commercial QResidenhsl Water Supply(shared)
ill.GROtZ
'nom I TO ytAtFR1A1. rs JQ'r 1_1CrrM Hip
MINT
METHOD A Asto rT
Nori-Water Supply Well: - IQ ' rt. jeo j/, f UJ / /3
as QRcrovcn' 1' rt n, r rt. /— (J l
Injection Well:
Q.igwfer Rhargc st ft. j R.
❑Gruunduater Rem:Minion
A 19.S AND'GRAA'EL PACK(lf applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM I To `MATERIAL. E'it PLACEMVia METHOD
Ci Aquifer Test QStorrnwater Drainage rt. T rt,
QExperimental Technology QSubsidence Control ft.1 ft.
Geothermal(Closed Loop) 1
P) Tracer 20.DRIL[1NG LOG(ateae0 additional sheets II necessary)
0 Geothermal(Heating Cooling Return) nOther(explain under 021 Remarks) FR°\I I TO
orNc H 110ti{cobs.bulimia"Area hp*.Ernie Naa cool
R. R
4.Date Wells)Completed: 1-24- 23 Well IDa T# R, rt.
Sa.Well Location: U it' 1 0 n' 5O f er 0 c
G pi Corsi ion Ul �/.cWeT 3 'so U5 - / vc
i
R. Ir � Tfn r
acility,OwnerName Sacra IDa ifs R. .I R•
+LP1 !( �OIICr I/0y1S4 i)r GtOlen At
R, R.
Physical Address.CM,and Zip/ I f �1�i6['U R, r R,
�' Ot/7T�J1�/J
C v/y La I,E CRC ,Y� !5iv lt,/c 7T 7 21.REMARKS
0' 1 Parcel identification No.(PIN)
5b.Latitude and longitude In degrees/minutesiseconds or decimal degrees:
(dwell field.one tatlong is sufficient) 22.Certification: a
N 1-a g-a3
6.Is(art)the wefl(s)0Permanent or QTemporan S tore of coin d c I Conrraa r Date
ugnteg;Ail form.I ile'61.,r. ty that rite t,rl7(s)rue(real axrtrv,Ye,l In acrstrdanar
7.Is this a repair to an existing well: Q Yes or Q No ��tirh I1.i NC.ic 02C.01Ut)or•a. V'C.IC 02C.0200(Pell Construction Standard;and tear a
{fthis is a repair,ill out morn well construction in/iernarmn and nxploin the nature(t/the `Clrpl u/dux retort(liar been prat r,/to the rrlf WOW.
repair under 0121 remarb section or on the back of rho form.
23.Site diagram or additional well details:
S.For GeoprobefDPT 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL.INSTRUCTIONS
9.Total well depth below land surface: ,C2 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For'multiple yells list all depths if different J�u 00 and 2. 1110) construction to the folios mg:: p
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
lfaour keel is above casing.use`-" 1617\lull Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection\\'ells: iit addition to sending the form to the address in 24a
Air Rotary abose, also submit one copy of this form within 30 days of completion of well
IL Well construction method: consuuction to the following:
(ie.auger,rotary.cable,direct push,etc.)
Dhisiun of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh.NC 17699-1636
I3a.Yield(gpm) Method of test: �I�I i I i 24c.For tN titer Supply ,tc Injection Wells: In addition to sending the form to
the addressles) above, also submit one copy of this form within 30 days of
1.34.Disinfection type: Chlor abs .Amount: 1 1'2 tit' completion of well construction to the county health department of the county
where constructed.
Form GW'-1 '.onh Carolina Department CI Ensironmenra,Qcaluy•Donjon of Water Resourres Roiled 2-22.2016
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