HomeMy WebLinkAboutWELL-07-2022-175701.TIF ct;zr. CATAWBA COUNTY' '
y/.+rw, 'Public Health Dgnnmem'f Subdivision WYNSWEPT PH 5.1'
lips`.p_,s •Environmental Health Division PINS 387804E119E12
'+t:rtt/ PO Boa 359,23 Oovenunem brie Newton,NC 22652 LOU 65 `'
site Address: 3204 TIMBER RUN LN,MAIDEN NC 28850
'Name on Permit 'NEST HOMES LLC -
' Property Mira: Acres 0.76
DO*COMIC S Hwy 18.Left Ceylon Dr Left N Wynswept Dr Right Timber Run LN
Owner/Authorized Representative Acknowledgement of Permit Receipt
jay
r I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
• the properly described above.
J�����y'v�As the property owner or authorized representative,I have received the above referenced •
I permit(s)as requested in the application for service RBPR-03-2022-40477,by the following method(s):
_ Received in Person
Facsimile Transmittal(Return form with signature required)
Electronic image Transmittal/E-mail (Return receipt required)
As the property owner or authorized representative 1 have reviewed and understand the specific conditions
of the permit issued, and further understand that all applicable regulatory requirements specified under the
f North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(ISA NCAC 1SA.1900),
and/or Well Construction Standards(1SA 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:07/14/2022
Owner/Authorized Representative Signature 4. '&rqn•
Date ?f/iq Jaa2-
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means) •
Permit transmitted by (, (name ofperson se dingpermir) .
Signature V Datepnme f���I?ol
Method: _Fax J Email __LIS Mall_ Other
Owner's request to send by the above Indicated method of transmittal In lieu of signature
We warn:tto hear from yoselease stake a few moments tto complette our custtomer service survey as
http://www.surveymenkay.com/s/EFICusttomerService
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WELL CONSTRUCTION RECORD (GW-1) Ir k Tit
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
'14.'WATER ZONES• :
Well Contractor Name FROM I'O DESCRIPTION
3271-A Q v n. au ft. in /' €/rviC Zdlge
NC Well Contractor Certification Number ft. ft.
B&K Well Drilling Inc 15.OUTER CASING(for multi-cased wells)OR LINER(ifapplicable) "
If fI DIAMETER TII CKNESS 11 MATERIAL
Company Name /� ^��t�1 (� 0 FROM ft. 1 T1!/O t ft. I /- /In. ! A.ti
bill"- 0'/'/I M a-/y> O/ 16..INNlER CASINGF OR TUBING.(ggeothermall cllos///eed lo) /./(r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List ail applicable well construction permits(i.e.UIC,County,State. Variance,etc) ft. ft. In.
3.Well Use(check well use): tt, ft in.
Water Supply Well: 17.SCREEN,.
QAgriLultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public n. ft. in.
°Geothermal(Heating/Cooling Supply) laResidential Water Supply(single)
°Industrial/Commercial ft. in.
Residential Water Supply(shared) 1B.CRpUT .;
hlrrigation FROM TO
Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD A.4atOUNT
o ft. 20 ft. Berate Pour
Monitoring °Recovery
Injection Well: ft. n•
°Aquifer Recharge ❑Groundwater Rcmediation ft. ft.
()Aquifer Storage and Recovery Salinity Barrier :19,SAND/GRAVELPACK(ifappllet(bte) ,
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stotmwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
20.DIt1LLLNG LOG{attach addltiooal sheets It necessary)'.
.}Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) FROM to DESCNIPT ry(eetor,hardness,eoi0ruck bye grain dze¢tc.)
7 9 / /•/" a ft. /5 ft. "
4.Date Well(s)Completed: 3/t ?/23 Well ID# Lal 4s ((�/ ���
Sa.Well is--ft. 3�tr. rZR/7/ SQ4
Location: ft. /0 ft. ye i� .0/
,yY ffi xS L`6 ^'/e5�✓��l S'. I oft. C6? rt. .they Sa� .1
Facility/Owner Name Facility ID#(if applcablc) 4 ? rt. `.0 ft. /Oyy/ 4a, Reek
34?03/ rail, it un LA! M4,441 ittV a e6ra jo ft- Jd(n. 6 ,,,� ,,J,�_ifoc (
Physical Address,City,and Zip /� 'I ft. ft.
C4rq bI CQ- 36)kow c 57.2. 21..REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certi cation: 46
N W + l�a/i a3
6.Is(are)the wells) Permanent or Temporary Sign urc of C ificd Well Contractor Dafc
By signing this form,I hereby ce ' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or FDNo with 15.4 NC4C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the cop}'of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GcoprobciDPT 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
j drilled:'
�� 1 r � SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths t,'f di•/Brent(example-3@200'and 2 f/00')
construction to the following:
10.Static b l water leveelow top of casing:40 ft.
If water level is a e el bet,use"+" ( ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: (in.)
/ 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /�Q T�`/ 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7l ai / Method of test: Airlift 24c.For Water Supply.4 lniection Wells: In addition to sending the form to
ChlorTabs t r/2Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form O W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
nr 1