HomeMy WebLinkAboutWELL-07-2022-174959.TIF ...
CATAWBA COUNTy
Public Health DemYnc.0 Subdivision i MT EIEUiAN EST
i
0 Environmental Health Division PINli .•389701393060
.141.7'-,......PO Box 389,25 Government Drive,Newton,NC 28658 tarts 9 *
t. Et :yr;
Sibs Address: . 3411 KINGS AVE,SHERRILLS'FORD NC 28873
Name on Permit EILEEN CONLEY
Property Size: Acres 0.47
otreetlens: 18 Business'to Mt Beulah R to Little Mountain R kings eve
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• Owitei/Attthor4e4 Representative Acknowledgement of Permit Receipt
. ....L., [pettily that II am,the owner,or Authorized agent(owner's authorization required)representing the owner of
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the property described above.
14s the property owner or authorized representative,I have received the above referenced • . - ,
ierntit(s)earequeStedin the application for service FilIPR444022-€10728,zby the fOliniiing.melbc4(s :
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Received in Person
i Facsimile Transmittal(Return form with signature required)
Electronic Image'Transmittal?E-mail (Return receipt required)
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. ..i •
• -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), 2 •
and/or Well Construction Standards(ISA NCAC 2C t0109),:shall apply to the issuance of this permit and
theconstnictionef the wastewater system and/or water supply well permitted.
Permilissue Date:07/01/2022
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Owner/Authorized Representative Signature
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' Date 74/0/7 0 2 2-- ' ...
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Documentation of Permit(s)Transmittal:
(permit transmitted by electronic or other means)
Permit transmitted by... (name 1i i
of person sending perm10
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I e. ..,
r.;.
Signature ,,,,.„,,, Date/tribl, ,7.. 1• . ,r
...
Method: Fax ALEmall VS Mail Other
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Owner's request to send by ihe above indicated method of transmittal in lieu of signature
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We wank to hear from yotPlease take a few inoirientts tto complete our custtomer service sttrOey at •
httprj/www.surveymenkey.com/s/EFICusftonterService
e ‘ti-no Kotiocoltotaa . .
Memnit 07/0i/2025 1015 ,
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` Print for
,l WELL C(.)NSTRl;41'R)\ RI':('tOR1) t(;\�..t1 l`iir Intern:II I'se t1n11- �
I.\1 col contrutor lnfortrtatlon:
Robert Teague 14.WAIF R i.uNr\ __.
Ara.onrriNrot\amr tows, to __ Isis PurliA\
2857-A G O"' 10 "' t/rl,^^
�n. n.
\t'Heil C critntow i ctttfw uh+n\umhor OUTER IS.OIITER CASINO(fie multi-cased welbt,OR LIN►R(If applkabk?
Well polling Inc saint to DIANErER ma _NATIRIM
o n. `7 n• a VS IN' PVCSOR•2r C
c,.,:,ian.y, ^
ZO — 7'1 S 16.pwvLK CLING OR tt101NG(R.ileb venal el.Ms.l.sp)
2.Well Construction Permit a:o I: a `1 i, !.film)_ fa— Molt FIR THII A\e.s\ MATiIIAI
C.sr at(yri«wNe.T,`I,1Ni.Mii. p..•m•t%tta (:A.(,wen S:Ni, lar,N+.r.eh . Otl. ft. �0 Irk
41d
3.Well tic(check well use); n. n. in.
W stet Supply Well: F7.$CREEN
FROM to DIAMITER IIOT.4171 TNICKYrM M1TFR1.11.
Q.igncultural DMunicipal Public ft. n, lo.
ftwvthernal[Heating Cooling Supplsl 10Res:demi:0 Water Supply(single) n. R.1 In.'
0Industna(Cortmtentai DNes)dcnnal Water Supply(shared) fE.GROLR
+l(mgatrn FROM TQ MATERIAL, Cs1Pl. ct.'4F TMITHOPA \r_
Non-Water Supph Well: R. ft.
C)Monitaring 0Rno+en n. n.
Injection\S ell:
0 Infer Rttha II. �ft.
q r �Cuioundwatcr Rcmaiimion i
QAqutta Storage and Recovery DSalin n Bamcr 19.SANDIGRA1'EL PACK(IfappUabl.)
FROM To j MATERIAL _ EM►L.AC►\IEsT METIIOD l
Aquifer Test DStornnsater Drainage n. n.
pExperimental Technology Subsidence Control ft. n. t
aG.vthemnal(Closed Loop) DTlacer 20.DRILLING LOC(attach atldlti.aal shoos Ifaseataary)
�Cmstherinal(heating Cooling Return) f Othcc(etplam under q21 Remarks) IwOOa 10 _ us:�(N1na\reeler,,.,.;rise wv.e Lk_ch np.,train aaa me.)
oft. 45 n.cJ '>r4 d /204.Date%fell(;)Completed:j O- 1 O-Z'1 1\ell IDa L13 3 n. ' '-rJ t] �- _ - 1
Sa.11'eu Location: rt. —"—Yu`� (1 —f, rii�
i�S S_ z.S-- cl_S4 r
l' .-lV1h1CUh3 [ rL rt.
—~
Fanh r.:,,t/rr Kane Faclhn ID'ill applicaFki I rt. ft. ~— -----
—1 I 1 Ri h5S A.trCAvc 31,trr1 l(r ,ty—d
— —
Physical AJdre-ss.Cl!..an4 Zip ft. ft.
Cc .al c Jy. II.RLM.ARKS
Cow Parcel Identification No (PIN)
Sb,Latitude and longitude in degrees/minutesisceoods or decimal degrees:
Orwell field.one to long is sufYcient)
22.Certificati_
N W 1z�.flp
6.h(are)the weIl(s)inPerminent or QTemporan• Signature of Certified t I Contractor Date
Hs ugniny ihn Arent, I hetrin cerigi (hat the urll(ci wus(were)rarstnn'ted in accordance
7.Is this a repair to an existing well: pees or 41io with l c-1.VC•IC 02C 0100 or 15r4.NCOC OK.0200 Well Construct/on Standards and Mai a
If this is a repair.fill out brans,nt/l c.wulruciwa injsirmalinn and explain the nature al the cvrp.ojihii re""4 hat hen yrnriikil m the"rig uw ser.
repatr under al ermanir;echo,.or on the back of this form
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction Details. You may also,.Hach additional pages ifntressary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
dolled: iSUUNI1TT.AL INSTRUCTIONS
9.Total well depth below land surface: —.C.b S (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths tf different(e-samp/r•i(•20i1.and Yrfilltrrl
construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of 11 aces-Resources,Information Processing Unit,
If weer keel is above casing.use " 1617 Hall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/8 (In.) 24h. For lniection Wells: In addition to sending the form to the address in 24a
12 Weil construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following
(re auger,rotary,able,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) 3 .lelhoti of test: Air Flow 24c./or W ate►SuDot) Sr tniection Wells: In addition to sending the form to
the address(ea) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ChiOr Tabs Amount: I l'2 tbs completion of well construction to the county health department of the county
where constructed.
Form GW I Nonh Carolina Department of Environmental Quality-Division of Water Resowem Rcvsrcd 2-22-2016