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HomeMy WebLinkAboutRBPR-09-2022-42259.TIF 83,A THIS IS NOTA PERMIT Case# RBPR-09-2022-42259 a CATAWBA COUNTY I IEALTII DEPARTMENT PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES /8 '" Residential Building Plan Review- Building New t NEW WELL -AOWE 1 51r7 f 3 Owner *SILAS DAVIS JR,PO BOX 1709.HIJNTERSVILLE NC 28070 C:7044914537 SIXPACK91I@GMAIL.COM NAME TO APPEAR ON PERMIT *Silas Davis Jr SITE ADDRESS: 4232 SIGMON COVE LN,TERRELL NC 28682 PIN# 461704508673 NAME of SUBDIVISION: THE VINEYARDS AT KISER Lot S 4 Section/Block PROPERTY SIZE: Square Feet Acres 0.85 DIRECTIONS: Hwy 150 t oKiser Island RDthen Left on Sigmon Cove LN PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS ER DAY: 480 WATER SUPPLY: Private Well DESCRIBE WOR 5/17/2023"AOWE SUBMITTAL RECEIVED 90X78 HOME 4 BEDROOM WITH 20X40 POOL _ PREVIOUS DESCRIPTION: New 2 story 4 bedroom Single Family Dwelling w/partial finished basement& attached garage; in-ground swimming pool 20x40 separate permit when issuance**Recorded deed attached SITE INFORMATION Do any of the following apply to the property for which this application is applied? If the answer to any of the questions below is"YES",then supporting documentation is required: Does this site contain any jurisdictional wetlands? No Does this site contain any existing wastewater systems? No Is any of the wastewater going to be generated on the site other than domestic sewage? No Is the site subject to approval by any other public agency? Yes Are there any easements or right-of-ways on this property? No APPLICATION FOR: New Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Single Family Residence OTHER DESCRIPTION: DESCRIPTION OF vacant lot EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS: 4 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 90X78 HOME 20X40 POOL #OF NEW BEDROOMS:: 4 BASEMENT? Yes BASEMENT FIXTURES? Yes PLUMBING REQUIRED? Desired system types(Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: YES OTHER: INNOVATIVE: ANY: Other described: APPLICATION FOR WELL CONSTRUCTION PROPOSED WELL TYPE: Individual Well REPLACE WELL?: NO ch:qpli :i • 05/17/2023 08:54 Page I of 3 cRBPRN CATAWBA COUNTY Case q -09-2022-42259 Public Health Department Subdivision THE VINEYARDS AT KISER . isi Environmental Health Division PINK 461704508673 PO Box 389,100-A Southwest Blvd,Newton,NC 28658 NAME ON PERMIT: (*SILAS DAVIS JR),PO BOX 1709,HUNfERSVILLE NC 28070 ('Silas Davis Jr) Site Address: 4232 SIGMON COVE LN,TERRELL NC 28682 Property Size: Square Feet Acres 0.85 Directions: Hwy 1501 oKiser Island RDthen Left on Sigmon Cove LN Completed applications are valid for a period of 2 years.Improvement Permits are valid:with complete site plan=60 months(5 years);with complete plat =without expiration. An Authorization to Construct will remain valid as long as the Improvement Permit is valid.An Authorization to Construct issued for septic repair is valid for 60 months(5 years).Permits may be revoked if the information on this application/site plan changes or if the intended use for the proposed facility changes. Permits may be revoked if site conditions are altered such that they effect permit conditions or installation requirements I have read this application and certify that the information provided herein is true,complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site accessible so that a complete site evaluation can be performed. The undersigned is the owner of the property or legal agent of the owner. Date: __ Signature of Applicant or Agent If you need further information or assistance please call 828-465-8270 AREA3 SETBACKS: 30 per UDO county; 50'from contour per state; Applicant will ensure there is a 15'min side setback FEENAME PATE FEE AMOUNT Authorization to Construct Fee(New/Expansion) 09/14/2022 S300.00 Fee Improvement Permit Fee 09/14/2022 S150.00 Well Permit&Inspection Fee 09/14/2022 S300.00 TOTAL FEES S750.00 FEES ARE NON—REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ON A PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) ebapplicnticm D5/17/2023 08:54 Page 2 of3 RECEIVED 1 7 2023 c a t a w b a county Environmental Health public health 6 jf'03 Retlisci+ z Mill Application for Environmental Health Services aipned THIS IS NOT A PERMIT Application is for: tEl New Constraction ❑Existing Facility © Improvement Permit IN Authorization to Construct ® New Septic ❑ Septic Repair/Malfunction ❑Septic Relocation ❑ Septic Expansion ❑Existing System Inspection or Reconnection ®New Well ❑Replacement Well ❑Well Abandonment ❑Well Repair Property Address 4232 Sigmon Cove Lane. Terrell, NC 28682 Acres 0.85 Subdivision The Vineyards at Kiser Lot# 4 Driving Directions to Property From Newton, take NC-16 South to NC-150 East. Turn left onto NC-150 East, right onto Kiser Island Road, and left onto Sigmon Cove Lane. Turn left and lot is located immediately on the right. Describe work Constructing new 4-bedroom single family residence Applicant Name Silas T. Davis, Jr. Applicant Address PO Box 1709, Huntersville, NC 28070 Phone Cell Phone 704-491-4537 Owner Name Owner Address Phone Same as above Cell Phone Contractor Name License# Contractor Address Phone Cell Phone Name to Appear on Permit? ®Owner ❑Applicant ❑Contractor Who will be the Primary Contact? ®Owner ❑Applicant El Contractor Proposed New Construction-Residential Primary Residence ® New Residence ❑ Addition to Residence #of New Bedrooms st_ 4 #of Occupants 8 Project Description Constructing new single family residence. Structure Dimensions,also specify dimensions of decks&porches 90-ft x 78-ft Basement E Yes ❑ No Basement Plumbing ®Yes El No Accessory Dwelling #of New Bedrooms*t #of Occupants Structure Dimensions Basement ❑Yes ❑No Basement Plumbing ❑Yes ❑ No Accessory Structure(s)Describe Pool Structure(s)Dimensions 20-ft x 40-ft Plumbing El Yes ®No Describe Plumbing Needed Multi-Family Residence #of Apartments #Bedrooms per Apartment*t Total#Bedrooms in Structure*t #of Occupants Structure Dimensions Basement ❑Yes ❑ No Basement Plumbing ❑ Yes ❑ No Well Construction/Abandonment/Repair Proposed Well Type ® individual Well El Semi-Public Well ❑Community Well Abandonment Type ❑ Drilled ❑ Bored El Dug El Unknown Well Repair Requested 0 Yes 0 No Describe Will Certified Well Contractor install Water Line or Electrical Line from Well Head to Pressure Tank?0 Yes ❑No catawbacountync.gov Environmental Health Catawba County Government Center 25 Government Drive I PO Box 389 I Newton NC 28658 1828.465.8270 MAKING. LIVING. BETTER. Existing Structures on Site Describe Structure Dimensions #of Bedrooms* #of Occupants Basement ❑ Yes ❑ No Basement Plumbing ❑ Yes ❑ No Existing Water Supply ❑Individual Well ❑ Shared Well—Number of Connections ❑ Community Well ❑ County/City/Township Water Line Is a public water supply available?** El Yes ❑No Commercial ❑ Proposed New Construction ❑Existing/Change of Use ❑ Repair Food Service Specify Type #Seats Dining Area(Sq.Ft.) #Employees per Shift #of Shifts Church #of Seats Daycare El Yes ❑No #of Children #of Employees per Shift #of Shifts Commercial Kitchen ❑Yes ❑No Residential Kitchen ❑Yes ❑No Daycare#of Children #of Employees per Shift #of Shifts Business/Other Specify Type Structure Dimensions Retail Floor Space #of Employees per Shift #of Shifts Other Information Calculated Design Flow,Commercial 1' (This value will be determined by EH staff) The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in question. If the answer to any question is"yes",applicant must attach supporting documentation. ❑Yes CI No Does the site contain any jurisdictional wetlands? ❑Yes El No Does the site contain any existing wastewater systems? ❑Yes ®No Is any wastewater going to be generated on the site other than domestic sewage? ❑Yes No Is the site subject to approval by any other public agency? ❑Yes ®No Are there any easements or right of ways on this property? Describe If applying for an Improvement Permit or Authorization to Construct,Please Indicate Desired System Type(s): (systems can be ranked in order of your preference) ❑Accepted 0 Alternative ❑Conventional ❑Innovative ❑Other Q9 Any *Any room that will be intended for sleeping at the time of construction or for future consideration should be noted as a bedroom and counted on all applications.The number of bedrooms will be confirmed by rooms identified on floor plans as a bedroom at the time of building permit issuance. This may prevent the need for septic system expansion in the future. t If structure is plumbed but has no bedrooms,calculated design flow will be determined by EH Staff. **If No,a well permit must be issued with the Authorization to Construct. RETRIP TO THE PROPERTY AND/OR SYSTEM REDESIGN WILL INCUR AN ADDITIONAL CHARGE(SEE FEE SCHEDULE) Completed applications are valid for a period of 2 years.Improvement Permits are valid:with complete site plan=60 months(5 years); with complete plat=without expiration. An Authorization to Construct will remain valid as long as the Improvement Permit is valid.An Authorization to Construct,issued for septic repair is valid for 60 months(5 years).Permits may be revoked if the information on this application/site plan changes or if the intended use for the proposed facility changes.Permits may be revoked if site conditions are altered such that they effect permit conditions or installation requirements. I have read this application and certify that the information provided herein is true,complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site accessible so that a complete site evaluation can be performed. The undersigned is the owner of the property or le: •nt .,•" e owner. Signature of Owner or Legal Agent $ - Date 05-16-23 fir Printed Name of Owner or Legal Agent L- ompson ��•'STATE',I,o ROY COOPER•Governor . am NC DEPARTMENT OF KODY H. KINSLEY•Secretary %�� = HEALTH AND R HUMAN SERVICES HELEN WOLSTENHOLME•Interim Deputy Secretary for Health MARK T. BENTON•Assistant Secretary for Public Health Division of Public Health COMMON FORM FOR AUTHORIZED ON-SITE WASTEWATER EVALUATOR PERMIT OPTION FOR NON-ENGINEERED SYSTEMS See instructions for Use in Appendix A Except for"Date received",this Section to be completed by the AOWE in accordance with G.S.130A-336.2 LHD USE ONLY: Initial submittal of this NOI received: _ by Dote 7nitiols PART 1: Notice of Intent to Construct(NOI)-Please check all that apply ❑■ Single System or ❑ Multiple Systems AND 0 New ❑ Expansion ❑Relocation of all or part of the Existing System ❑Relocation of Repair Area ❑ Repair—LFID Permit Number ❑ Repair—EOP/LSS COVID 19/AOWE Permit Number 1. Facility Owner's name: (Owner,Company Name, Utility, Partnership, Individual,etc.): Silas T. Davis, Jr. Mailing address: PO Box 1709 City: Huntersville State: NC Zip: 28070 Telephone number: 704-491-4537 E-mail Address: sixpack911@gmail.Com 2. Authorized On-Site Wastewater Evaluator(AOWE)name: Larry Thompson LSS License number:1208 AOWE Certification number: 10016E Mailing address: PO Box 541 City: Midland State: NC Zip: 28107 Telephone number: 704-301-4881 E-mail Address: larry@thompsonenv.com 3. Licensed Geologist(LG)(if applicable)name: N/A License Number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 4. Proof of Errors and Omissions or other appropriate liability insurance for the following persons is attached that includes the name of the insurer,name of the insured and the effective dates of coverage: ❑■ AOWE ❑ LG 5. Property location(physical address,tax parcel identification number or subdivision lot, block number of the property to be permitted): 4232 Sigmon Cove Lane, Terrell, NC 28682 (Parcel: 461704508673) County Name: Catawba NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION 5605 Six Forks Road,Raleigh, NC 27609 MAILING ADDRESS:1642 Mail Service Center,Raleigh,NC 27699-1642 www.ncdhhs.gov • TEL:919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY 1 AFFIRMATIVE ACTION EMPLOYER AOWE Common Form LHD Reference: 6. Type of facility: [ Place of residence No. Bedrooms: 4 No.Occupants:8 ❑ Place of business Basis for flow calculation: Lf Place of public assembly Basis for flow calculation: 7. Factors that would affect the wastewater load: Proposal is for domestic wastewater strength only. 8. Type and location of proposed wastewater system: Gravity flow Prefabricated Permable Block Panel System located behind the house. System classification Type Ille. 9. Design wastewater flow: 480 gpd Design wastewater strength: ❑domestic ❑ high strength ❑ industrial process(For high strength and industrial process wastewater,a Professional Engineer licensed in accordance with G.S.89C shall design the on-site wastewater system.) 10. A plat as defined in G.S. 130A-334(7a)is attached: [ Yes [ No A site plan as defined in G.S. 130A-334(13a)is attached: ElYes ❑ No 11. Location of proposed or existing wells(drinking water, irrigation,geothermal,groundwater monitoring, sampling,etc.)and any potable and non-potable water conveyance lines is indicated on attached plans and complies with 15A NCAC 18A.1950: ■❑Yes ❑ No This is a saprolite system. ❑Yes 0 No 12. Evaluation(s)of soil conditions and site features in accordance with G.S. 130A-335(a1)signed and sealed by a LSS is attached: Yes ❑ No 13. Evaluation of geologic and hydrogeologic conditions signed and sealed by a LG is attached ❑Yes ❑U NA 14. Proposed landscape,site,drainage,or soil modifications are attached: ❑Yes ❑■ NA Attestation by AOWE pursuant to G.S. 130A-336.2 Larry Thompson hereby attest that the information required to be included with Authorized On-Site Wastewater Evaluator(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal, State,and local laws, regulations, rules and ordinances, and that the proposed system does not require a Professional Engineer, licensed in accordance with G.S.89C,and in accordance with 15A NCAC 18A.193 d activities determined to be engineering as determined by the North Carolina Board of Examiners for rs Surveyors. 05-16-23 Signature of uthori7 mSite Wastewate aluator Date (Owner self-submittal of N01: hereby submit this NOI prepared by Print Name of Owner Print Name of Licensed PE pursuant to G.S. 130A-336.1. Signature of Owner Date DHHS/EHS/OSWP-AOWE COMMON FORM Updated April 2022 Page 2 of 6 AOWE Common Form LHD Reference: NOTES: LIABILITY: The Department the Department's authorized agents,or local health departments shall have no liability for wastewater systems designed,constructed,and installed pursuant to an AOWE Permit Option jG.S.130A-336.20 RIGHT OF ENTRY: The submittal of this Notice of Intent to Construct grants right of entry to the Local Health Department and the State to the referenced property. ISSUANCE OF BUILDING PERMIT: Once the LHD deems that the Notice of Intent to Construct is complete via signature in the section below,the owner may apply to the local permitting agency for a permit for electrical,plumbing,heating,air conditioning or other construction,location,or relocation activity under any provision of general or special law pursuant to G.S.130A-338. DHHS/EHS/OSWP—AOWE COMMON FORM Updated April 2022 Page 3 of 6 AOWE Common Form LHD Reference: This section for Local Health Department use only. PART 2: LHD Completeness Review of the Notice of Intent to Construct "(c) Completeness Review for Notice of intent to Construct.—The local health department shall determine whether the notice of intent to construct required pursuant to subsection(b)of this section is complete within five business days after receiving the notice of intent to construct.A determination of completeness means that the notice of intent to construct includes ail of the required components.If the local health department determines that the notice of intent to construct is incomplete,the local health department shall notify the owner and list the information needed to complete the notice. The owner may then submit additional information to the local health department to cure the deficiencies in the initial notice. The local health deportment shall make a final determination as to whether the notice of intent to construct is complete within five business days after the department receives the additional information. if the local health department fails to act within any time period set out in this subsection, the owner may treat the failure to act as a determination of completeness. The owner shall be able to apply for the building permit for the project upon the decision of completeness of the notice of intent by the local health department or if the local health deportment fails to act within the five business day time period." The review for completeness of this Notice of Intent was conducted in accordance with G.S. 130A-336.2(c). This NOI is determined to be: ❑ INCOMPLETE (If box is checked, Information in this section is required.) Based upon review of information submitted in Part 1,the following items are missing: Copies of this form listing missing items were sent to the AOWE and the Owner on Date via with directions to re-submit missing items using Page 5 of this form. Email,FAX,USPS,hand-delivered Print Nome of Authorized Agent of the LHD Signature of Authorized Agent of the LHD Date ❑ COMPLETE(If box is checked, information in this section is required.) Based upon review of information submitted in Part 1 of this form,this NOI is deemed COMPLETE. Copies of this signed form were sent to the AOWE and the Owner on via Date Email,FAX,USPS,hand-delivered A copy of this NOI and tracking information was sent to the State on via Date Email,FAX,USPS,hand-delivered Print Name of Authorized Agent of the 11-ID Signature of Authorized Agent of the LHD Date DHHS/EHS/OSWP—AOWE COMMON FORM Updated April 2011 Page 4 of 6 AOWE Common Form LHD Reference: Re-submittal of NOI with missing items included This Section is for use by owner to submit items noted as missing during LHD Completeness Review above. Resubmittals must be accompanied by a cover letter from the ROWE. LHD USE ONLY: This NOI resubmittal received: by Dote Initials Item#from initial NOI Resubmittal description Attestation by AOWF certified in North Carolina pursuant to G.S.130A-336.2 I, hereby attest that the information required to be included with Authorized On-Site Wastewater Evaluator(Print Name) this Notice of Intent to Construct is accurate and complete to the best of my knowledge and that the proposed system shall meet applicable federal,State,and local laws,regulations, rules, and ordinances. Signature of Authorized On-Site Wastewater Evaluator Date The section below Is for Local Health Department use after submittal of items noted as missing above. LHD Follow-up Completeness Review of Notice of Intent to Construct This follow-up review for completeness of this Notice and Intent was conducted in accordance with G.S. 130A- 336.2(c), This NOI is determined to be: ❑ INCOMPLETE Based upon review of information submitted in the RESUBMITTAL above,this Notice of Intent remains INCOMPETE because the following items from Part 1 of this form remain missing: Copies of this signed form were sent to the AOWE and the Owner on via Date Email,FAX,USPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Dote ❑ COMPLETE Based upon review of information submitted in the RESUBMITTAL above in addition to information provided in Part 1 of this form,this NOI is deemed complete. Copies of this signed form were sent to the AOWE and the Owner on via Dote Email,FAX,LISPS,Hand-delivered A complete copy of this form with tracking information was sent to the State: via Date Email,FAX,USPS,hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date DHHS/FHS/OSWP-AOWE COMMON FORM Updated April 2022 Page 5 of 6 AOWE Common Form LHD Reference: PART 3: Authorization to Operate(ATO) Except for date received,the Section below is to be completed by the Owner. LHD USE ONLY: Initial submittal of request for ATO received: by Dote Initials Date of Post-construction Conference: T The following items are included in this submittal for an Authorization to Operate under an AOWE permit: 1. Signed and sealed copy of the AOWE's report that includes the information in G.S. 130A-336.2(k) ❑Yes ❑ No 2. Operation and management program ❑Yes ❑ No 3. Fee (as applicable) ❑Yes ❑ No 4. Notarized letter documenting Owner's acceptance of the system from the AOWE ❑Yes ❑ No S. On-site Wastewater Contractor name: License number: Mailing address: City: State: Zip: Telephone number: E-mail Address: 6. Proof of Errors and Omissions or other appropriate liability insurance for the On-site Wastewater Contractor is attached and includes the name of the insurer, name of the insured,and the effective dates of coverage. ❑Yes ❑ No Attestation by the Owner for Authorization to Operate hereby attest that all items indicated above have been provided to the Print name of Owner County LHD and the system shall meet applicable federal,State,and local laws, regulations,rules,and ordinances. Signature of Owner Dale This section for!HD Use Only, LHD Review of required information for the ATO INCOMPLETE Based upon review of information submitted in the Section above, the following items are missing from the information required for an Authorization to Operate for an AOWE permit: Copies of this signed form were sent to the AOWE and the Owner on via Date Email,FAX,LISPS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ❑ COMPLETE Based upon review of information submitted in the Section above,this Authorization to Operate is hereby issued in accordance with G.S. 130A-336.2(m). A copy of this complete NOl/ATO with tracking information was sent to the State on via Date Email,FAX,DVS,Hand-delivered Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date ISSUANCE OF CERTIFICATE OF OCCUPANCY; Once the LHD determines completeness based upon the ATO submission,the owner may apply to the local permitting agency for permanent electrical service to a residence,place of business or place of public assembly pursuant to G.S.130A-339. DHNS/ENS/OSWP—AOWE COMMON FORM Updated April 2022 Page 6 of 6 DOCUMENTATION TO AUTHORIZE AN OWNER'S LEGAL REPRESENTATIVE Applications for permits require the "signature of the owner or owner's legal representative" (15A NCAC 18A.1937). If the owner does not sign the application himself or herself, they can submit any one of the following documents to designate their legal representative: 1. Power of Attorney 2. Real Estate Contract 3. Estate executor 4. Bankruptcy trustee S. Court ordered guardianship In the absence of the above documentation, the property owner may provide the local health department with documentation that designates a legal representative. A property owner may: 1. Complete this form to document his or her legal representative, or 2. Provide their own form that contains the information in this form. If there are multiple property owners, then all property owners must sign the form that designates a legal representative. By signing a form that designates a legal representative for purposes of ISA NCAC 18A.1937, the property owner authorizes that representative to act on their behalf in matters pertaining to the application and permitting process, including signing or receiving any application, document or permit. The owner retains full responsibility to meet all permit conditions specified by the local health department. Silas T. Davis, Jr. am the legal owner(s) of the property located at 4232 Sigmon Cove Lane, Terrell, NC 28682 identified as PIN (Parcel Identification Number) 461704508673 located in Catawba County, North Carolina. I do hereby authorize(print legal representative/company name) Larry Thompson, LSS Thompson Environmental Consulting, Inc. ,to act as an agent on my behalf in applying for/signing/obtaining any of the documents described below. • Application for Improvement Permit {IP) /Authorization to Construct (AC) • Improvement Permit (IP)/Authorization to Construct(AC) • Application for soil site evaluation (new/repair) • Application/permit for private drinking water well/well abandonment • Application for Compliance Inspection I agree to abide by all decisions and/or conditions between the legal representative acting on my behalf and the Catawba County Department of Public Health, Environmental Health Division. SilasT Davis Jray 16,2023 18:10 EDT] May 16,2023 Angela Thompson(May 16,2023 18:41 EDT) May 16,2023 Signature of Owner(s) Date Signature of Witness Date ACORD- CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYY) 9/7/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: David Vaughan Higginbotham Insurance Agency, Inc. PHONE - PAX 500 W. 13th Street -CA/.c No.Extt:9187797880 I(NC,Nei:817-882-9284 Fort Worth TX 76102 ADDRESS: dlvl� q r hi,ginbotham.net INSURER(S)AFFORDING COVERAGE NAIC# License#:2081754 INSURER A:Mid-Continent Casualty Company 23418 INSURED THOMENV-01 INSURER B:Hartford Underwriters Insurance Company 30104 Thompson Environmental Consulting, Inc. -- PO Box 541 INSURER C: Midland NC 28 1 07-054 1 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1600075032 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE jADDL SUBR POLICY EFF POLICY EXP D/ LIMITS INSD WVD POLICY NUMBER (MM/DYYYYI IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 04-GL-001086672 9/25r2022 9/25/2023 EACH OCCURRENCE S 1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISESO(EaENTED occurrence) S 100,000 X Professional MED EXP(Any one person) $Excluded PERSONAL 8 ADV INJURY $1,000,000 _ GER'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY JET LOC PRODUCTS-COMP/OR AG G S 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ IEa accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ 6 WORKERS COMPENSATION 38WECNW6175 10/17/2022 10/17/2023 X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNERIEXECUTIVE N!A E.L.EACH ACCIDENT $1,000,000 OFFICERlMEMBEREXCLUDED? I . (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Informational Purposes AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Residential Subsurface Wastewater Treatment and Disposal System AOWE Permit for Lot 4 — The Vineyards at Kiser 4232 Sigmon Cove Lane Terrell, NC 28682 Tax Parcel Number: 461704508673 May 16, 2023 Prepared for: Silas T. Davis, Jr. A0.1mo41,0_ PO Box 1709 `c` • Huntersville, NC 28070 .l° 4 704-491-4537 Prepared by: .,J. Larry Thompson, REHS, LSS `��•w��j'�� Thompson Environmental Consulting, Inc. •. PO Box 541 erceruncati2n Midland, NC 28107-0541 ii i Numbs. ti Phone: 704-301-4881 � 10016E •• Fax: 206-350-8895 - ••. ti tarry@thompsonenv.com _ �' ••'"••'••• er 0, 1 Details Silas T. Davis,Jr. has contracted with Thompson Environmental Consulting, Inc.(TEC)to prepare an AOWE septic permit package for a 4-bedroom single-family residence to be constructed at 4232 Sigmon Cove Lane, Terrell, North Carolina (Catawba County Parcel Number: 461704508673). Based upon a soil and site evaluation performed by TEC, it was determined that a sufficient amount of"Provisionally Suitable" Group IV soils are available for the initial installation and repair of a Horizontally Installed Gravity-Flow Prefabricated Permeable Block Panel System for a 480 gal Ion-per-day residence at a 0.3 GPD/sq/ft long-term acceptance rate (LTAR). The property will be served by a private well. This proposal is being submitted pursuant to and meets the requirements of G.S. 130A-336.2. (AOWE Permitting). Location From Newton, take NC-16 South to NC-150 East. Turn left onto NC-I 50 East, right onto Kiser Island Road, and left onto Sigmon Cove Lane. Turn left and lot is located immediately on the right. References Laws and Rules for Sewage Treatment and Disposal Systems, 15A NCAC 18A, Section .1900, Department of Environment and Natural Resources, Division of Environmental Health, On-Site Wastewater Section, April 1, 2017. Design, Installation and Maintenance of the T&..1 Panel Wastewater Treatment System;published byT&fPanel, 2021. Primary Investigator's Credentials NC Registered Sanitarian No. 1208 NC Licensed Soil Scientist No. 1287 NC Authorized Onsite Wastewater Evaluator No. 10016E SC Certified Professional Soil Classifier No. I I 1 NC Subsurface Septic System Operator No. 22199 NC Grade IV Wastewater System Installer No. 1762 NC Certified Wastewater System Inspector No. 17621 Plans and Specifications A. Septic Tank 1. The septic tank shall be State approved (Section .1953 of l5A NCAC 18A), watertight, structurally sound, and 1,000 gallons in capacity (minimum). 2. The septic tank will be fitted with an approved effluent filter and riser for easy access and periodic maintenance. 3. It is the responsibility of the septic contractor to thoroughly inspect the septic tank prior to accepting delivery to assure that the tank has had time to properly cure and is free of cracks or other structural deficiencies. B. Pipes and Fittings I. All discharge piping, connectors and supply lines should be made of SCH 40 PVC. 2. All joints must be properly "welded" utilizing the appropriate PVC cement for each application. C. Distribution Method 1. Individual drainlines shall he evenly fed via a distribution box. 2. Distribution box shall be water tested for equal flow at the time of the final inspection. D. Backfill 1. Backfill sand shall be clean, washed, medium sand that is naturally occurring and falls within the gradation of ASTM C-33 specification (used in the ready-mix industry and is readily available). Properly compact backfill to provide the intended subgrade support. E. Drainfield Installation 1. The drainfield and the proposed septic tank location have been marked on-site utilizing metal stemmed flags. Once this area has been approved by the county, the property owner/builder should mark this area and isolate it as much as possible from construction traffic. Prior to the system installation, the septic contractor shall contact the designer for a preconstruction conference at which time the drainfield area will be re-verified. 2. Under no circumstances shall any construction take place within the drainfield area while the soil is in a wet condition. If the installer has doubts as to whether or not the drainfield area is dry enough to begin construction, the environmental health specialist for this area should be contacted for permission to proceed with the installation. 3. The specified system is a Type V(e) pre-fabricated permeable block panel system — specifically the prefabricated permeable block panel system manufactured by T&J Panel Wastewater Treatment System, Patent No. 4013559; telephone: 1-800-222-2577. The installer must follow the manufacturer's guidelines for installing the T&J Panel System and should request an installation manual from the manufacturer prior to beginning construction. 4. The initial drainfield consists of four (4) laterals constructed 3-feet wide by 67-feet in length. 5. It is essential that the lateral trenches be constructed on contour with the land, with each trench being excavated level from beginning to end. The use of a tripod mounted engineer's level is essential to assure that each trench is constructed as level as possible. 6. The required trench depth for this system shall be 23-inches. Each trench shall be placed on a minimum of 9-foot on centers. 7. Once trenches are dug,the side walls shall be raked, and a light dusting of lime applied. 8. Backfill the trench with 7-inches of sand and level to grade properly compacted to intended subgrade support. Once leveled,place 1 x 6-inch boards on top of the sand the entire length of each trench. Once the grade boards have been set, the panels may be set into the trench. The panels should be placed 6 inches apart. 9. Once the panels have been set, line the top portion of each chamber with the T&J supplied sand alternative product (SAP—geotextile fabric). GE Foam Sealer or tar seal rope should be placed in the bottom of the "U" outs to form seals around the pipe as shown in earlier drawings. 10. Tar seal rope, or approved foam, should be placed in the"U" outs of each end of the panel to form seals. Once the tar rope is in place, the 1%a inch Schedule 40 PVC connectors can be added, and the seal completed by the addition of more tar rope on the top and sides of the pipe. Now that the connection and seals are complete, a block cap is placed on each end of the panel so that all openings are covered. 11. Once the lateral has been installed and the panels closed, the trench is ready to be backfilled to the top with the sand used in the trench bottom. At this point,the trenches should be left open for the final inspection by the local health department. F. Final Landscaping 1. The drainfield shall be shaped to shed rainwater and be free from low spots. 2. Final cover requirement over the drainfield area is 6-inches. 3. The entire area of the drainfield should be planted with grass as soon as possible to prevent erosion. The soil should be properly tilled, limed (if necessary) and fertilized prior to planting. After applying grass seed,the area should be heavily mulched with straw or other suitable material. Maintenance H. In General 1. The homeowner must maintain the drainfield area through periodic mowing. The drainfield must not be allowed to become overgrown. 2. The septic tank should be pumped every 4 years or when the solids within the septic tank reach an elevation that is equivalent to 25 percent of the volume of the tank. In some situations, the tanks may need to be pumped more frequently. If using a garbage disposal, it is recommended that the homeowner has the septic and pump tanks cleaned out annually. 3. Use of a garbage disposal is not recommended. Solids added through the garbage disposal tend to degrade at a very slow rate. 4. Grease, cooking oils, coffee grounds and non-degradable solids (disposable diapers, cigarettes, and solid paper wastes) should never be put into a septic tank. 5. Used motor oil or any oily liquids should not be disposed of in a septic tank. 6. Be aware of the amount of water that you are using in your home. Water saving fixtures and devices can be installed on sinks, toilets, and showers to reduce the volume of wastewater that you are sending to your drainfield. 7. Run dishwashers and washing machines only when you have a full load. 8. Repair leaky faucets and toilets. Small drips equal large volumes of water over time and can over burden your drainfield. 9. Do not use chemical additives in your system. Studies have indicated that they do not increase the biological activity that naturally occurs in the septic system and in some cases certain additives have been found to be detrimental to the life of a system. Design Specifics Daily Design Flow: 480 GPD Septic Tank Size: 1,000 Gallons Effluent Loading Rate: Design =0.3 GPD sq. ft. Drainfield Type: Horizontal PPBPS Distribution Method: Distribution Box Number and Size of Drainlines: (4) 3-ft Wide x 67-ft Long Maximum Trench Depth: 23 Inches Drainline Spacing: 9 Foot on Centers Total Length of Drainline: 268 Feet Total Number of Panels: 60 Repair Specifics Effluent Loading Rate: Design = 0.3 GPD sq. ft. Drainfield Type: Horizontal PPBPS Distribution Method: Distribution Box Required Linear Footage: 267 Feet Available Linear Footage: 268 Feet Maximum Trench Depth: 20 Inches *See septic layout for site locations and additional details. --- - —1 vi al act 93.66' —y r r ?( N 02.21'20•E- - • • Ile ir 46.97' -, - - o I p cn cn rn r r' Q D O 14 Q I ,0' SCF PCSi.+PYt fD ' r*. D /// lad' fAs£etNr co co LO ___ r<o - r= co PAVEMEI�F i �' — — — — — —•4%frll]C 0_ , o �-. J —_ _ __ _.. 73 F,.nt—Setback o 0 FT-1 � sr ' W m x/ i ' •• o gli up d O N N ° ' ' r- n ; % o r+j S+I Po a r 0 o bb 20 3' o co rr OCa O (D �- CT ��1 ' f, tiv ^. Lri �- '14' A `A o CAis2 , o y o Proposedo -- ly 0 I` IOW i 2p00f;o I, Ali _— W ,4 rlr l i — IT T �cn i w Q "H't U W Allibli+ fi b' •"'‘. ;+ n . / �6 o qrL N s �A R? in i,, -sr `o r��..rrr' A -104174111 I '-' A It/it N. .ry�q e Nam / 0 r'�� � be• 14, s $ 4 J)° �i}dD/N° v 7 'r IRO y o R y o ,/ 9 � At*�I6! I A;74 oy aI m cn ~ d N �� O. co C IV ono N C)N K. -n Cn , 1 cn r rnQ �• D x rtiir w Z ro a C QQ ait 1 Thompson Environmental Consulting, Inc. Sheet 1 _of 1 PO Box 541 PROPERTY ID#: 461704508673 Midland, NC 28107 COUNTY: Catawba SOIL/SITE EVALUATION for ON-SITE WASTEWATER SYSTEM OWNER: Silas T. Davis, Jr. ADDRESS:PO Box 1709, Huntersville, NC 28070 DATE EVALUATED: 7-29-22 PROPOSED FACILITY: Residence PROPOSED DESIGN FLOW(.1949): 480 GPD PROPERTY SIZE: 0.850 acre LOCATION OF SITE: 4232 Sigmon Cove Lane, Terrell, NC 28682 PROPERTY RECORDED: WATER SUPPLY: ['Private ❑Public ❑Well ❑Spring ['Other Lot 4—The Vineyards at Kiserd EVALl IATION METHOD: ❑✓ Auer Boring ❑Pit ❑Cut TYPE OF WAS'I'1iWATER: El Sewage 0 Industrial Process ❑Mixed P R 0 SOIL MORPHOLOGY OTHER F (.194I) PROFILE FACTORS I .1940 L. LANDSCAPE HORIZON E POSITION/ DEPTH 1942 PROFILE N SLOPE% (IN.) .1941 .1941 SOIL .1943 .1956 .1944 CLASS STRUCTURE! CONSISTENCE/ WETNESS/ SOIL SAPRO RESTR &I;r 1R TEXTURE MINERALOGY COLOR DEPTH CLASS IIORIZ 0-4 GR/SL FR/NS/NP/NEXP 4-36 SBK/C Fl/S/P/SEXP 1 PS 22�0 36-40 SBK/CL FR/SSISP/SEXP 40" 0.3 0-4 GR/SL FR/NS/NP/NEXP 4-37 SBKJC FI/SIP/SEXP 7 LS PS 22% 37-42 SBK/CL FI/SSISP/SEXP 42" 0.3 0-3 GR/SL FR/NS/NP/NEXP 3-36 SBK/C FI/S/PISEXP LS PS 36-44 SBK/CL FI/SS/SPISEXP 41' PS 22% 0.3 ,0-5 GR/SL FR/NSINP/NEXP 5-34 SBK/C Fl/S/P/SEXP PS 22% 34-43 SBK/CL FI/SS/SPISEXP 43" 0.3 DESCRIPTION INITIAL SYSTEM REPAIR SYSTEM OTHER FACTORS(.1946): ,,,"p Spin SITE CLASSIFICATION(.1948): Provisionall Suit-;j fit;' ,of Available Space(.1945) PS PS Irk- z; System Type(s) PPBPS PPBPS EVALUATED BY: L. Thom.son, LSS % `;s- O`I HER(S)PRESENT: � l��: iiy,0r� . Site I.1'.1R 0.3 0.3 f At .' COMMENTS: . -. /_�,�I AtiR.n Updated February 2014 I LEGEND use the fidlowing standard abbreviations Soil. CONVENTIONAL LPP MINERALOGY/ LANDSCAPE POSITION GROUP TEXTURE ,1955 LIAR* ,1957 LTARa CONSISTENCE STRUCTURE CC(Concave Slope) I S(Sand) 1.2-0.8 0.6-0.4 SEXP(Slightly Expansive) G(Single Gram) CV(Convex Slope) LS(Loamy Sand) EXP(Expansive) M(Massive) D(Drainage Way) CR(Crumb) DS(Debris Slump) II SL(Sandy Loam) 0.8-0.6 0.4-0.3 GR(Granular) FP(Flood Plain) L(Loam) SBK(Subangular Blocky) FS(Foot Slope) ABK(Angular Blocky) H(Head Slope) III Si(Silt) 0.6-0.3 0.3-0.15 PL(Platy) L(Linear Slope) SiCL(Silty Clay l.oant) PR(Prismatic) N(Nose Slope) CL(Clay Loam) R(Ridge) SCL(Sandy Clay Loam) MOIST WET S(Shoulder Slope) SiL(Silt Loam) T(Ter(Terrace) VFR(Very Friable) NS(Non-sticky) IV SC(Sandy Clay) 0.4-0.1 0.2-0.05 FR(Friable) SS(Slightly Sticky) SIC(Silty Clay) FI(Firm) S(Sticky) C(Clay) VFI(Very Firm Very Sticky) VS(Very Sticky) 0(Organic) None None EFI(Extremely Firm) NP(Non-plastic) SP(Slightly Plastic) *Adjust LTAR due to depth,consistence,structure,soil wetness,landscape,position,wastewater flow and quality. P(Plastic) NOTES VP(Very Plastic) HORIZON DEPTH In inches below natural soil surface DEPTH OF FILL In inches from land surface RESTRI(7IVE HORIZON Thickness and depth from land surface SAPROLITE S(suitable)or U(unsuitable) SOA.WEr+IFss Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less-record Munsell color chip designation CLA, 1F7('ATION S(Suitable),PS(Provisionally Suitable),or U(Unsuitable) Evaluation of saprolite shall be by pits. Long-term Acceptance Rate(LTAR):gallday/R2 Showprofile locations and other site features(dimensions,reference or benchmark,and North. __.I-- 1- - —. I ]1_________,_:..._. _ SEE ATTACHED FIGURE - t Updated February 2014 NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES VARIANCE APPLICATION FOR 2C.0100 WELL CONSTRUCTION STANDARDS: PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300 WATER SUPPLY WELLS UNDER 15A NCAC 02C.0107 All water supply wells not considered"Private Drinking[rater Wells-and including irrigation,industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or t}pe information. Illegible submittals will be returned as incomplete. DATE: 6 ! , 20 2 3 PERMIT NO.: _(to be completed by DWQ/DPH) A. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the business, organization,or government agency and person delegated signature authority: Ste A i 745roora RI /9A1/44S/ 7/1- Mailing Address: 1q0 QQx / 70 City:,U/'y'GY$j/I'J!ei StateNG Zip Code?0 County: 7Ueghte,1'Qv/Day Tele No.: Cell No.: 709—� < // ` ! S -L^7 3 / EMAIL Address: S, Afa Lk�7I42/,,,Rsz-401 Fax No.: B. PHYSICAL LOCATION OF WELL SITE / � / (I) Parcel Identification Number(PIN)of well site: 1/4C/7 D f7 S o5�7 73 County: CATA it,t3A U (2) Physical Address(if different than mailing address): ill 3.7— 516/7Q� 49 V� hA-) City: 7 6 R Et L State: NC Zip Code: 2b6 2 C. WELL DRILLER INFORMATION (if known) NOT i<4"11 A) YET- Well Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person: City: State: Zip Code: County: Day Teic No: Cell No.: EMAIL Address: Fax No.: Form GW-22V Page 1 Raised February 2913 D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is being requested; description of how the alternate construction will not endanger human health and welfare and the environment;and reason why construction and/or operation in accordance with the standards is not technically feasible and/or provides equal or better protection of the groundwater. Sv/opz y /rives GO�ivG?"o •9 R.e=�As/Z aoptiem607) cA o,1 i 5 my- L m-- 7 ' Gar So' -/3 /4 7-ro,✓ .2'5 4955 7 ,9,'V 25 i4-/2o, /et-5 rQC�it/G�. E. ATTACHMENTS—Provide the following information as attachments to this application: (I) A map showing general location of the property (including road names, NC State Route Number, distances, any key andmarks,etc.)sufficient for finding the well location. (2) Detailed site map with scale showing location of proposed well relevant to septic sys:em(s), building foundations,property lines,water bodies,potential sources of contamination,other wells,etc. (3) Submit a copy of the local well permit application and site evaluation map(if applicable). (4) Any other information relevant to the variance request such as a well construction diagram showing proposed well liner or atypical construction materials/methods. F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional construction requirements beyond those specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of:his application. Approval of a variance will not be considered in cases where the specified minimum additional construction requirements cannot be met. G. SIGNATURES Signature of Person Responsible for Well Construction(typically the well driller) l'rint or Type Full Name of Person Responsible for\fell Construction (typically the well driller) . .f11 1 Signature of County Environmental Health Specialist J 4I,.. Piii r Print or Type Full Name of County Environmental Health Specialist Per 15A 111C4C 02C.0118 the Secretary of the Division of[Pater Quality or the Division of Public Health may require submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as described in G.S. 150B-23 within 60 days after receipt of the decision. Form GW-23\' Pace 2 Revised February 2013 42 3 a- J' m on COW Lh 1 I i Frame _-I,L ..)4i42 . i, I-, (. : / �o Q 1 (I,(,v� / rL. t 4, , ir i f+L ____.,„..„...,-------, ______ 02_2:1,, .....„,„ , _____ ,, �Esr 7,s' ROY COOPER • Governor ,„ off CO � . , jl NC DEPARTMENT OF KODY H. KINSLEY• Secretary HEALTH AND \14d `� c; HELEN WOLSTENHOLME• Interim Deputy Secretary for Health .,,_ HUMAN SERVICES •�"'" „« MARK T. BENTON •Assistant Secretaryfor Public Health .: &pvak/� Division of Public Health Onsite Water Protection Branch June 23, 2023 Silas Terry Davis Jr. PO Box 1709 Huntersville, NC 28070 Re: Approval No. JMB3060 Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C .0107(a)(2)(P)] Property location: 4232 Sigmon Cove Lane Terrell, NC 28682 Dear Mr. Davis: On June 16, 2023, the On-site Water Protection Branch received your request for a variance from the Well Construction standards, Title 15A North Carolina Administrative Code Subchapter 2C .0100. The request for a variance concerns a proposed water supply well on the referenced property that will serve a single-family dwelling and part of a structure on the property will be within twenty-five feet of the well. The home is on a lot with very difficult topography. Specifically, the variance request grants you permission to construct a water supply well at a distance closer than the twenty-five-foot setback to a building perimeter. Achieving the twenty-five-foot setback would be difficult given the challenges of the property. Based upon information provided by the Catawba County Health Department, and the property owner, it is my finding that based upon current conditions as the site exist today (as well as the current proposal for use of the structure) you meet the conditions necessary for approval of a variance as specified by 15A NCAC .0118 (a) (1) and (2). On that basis and if the following conditions are met, the requested variance is approved: NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF PUBLIC HEALTH LOCATION:5605 Six Forks Road,Raleigh, NC 27609 MAILING ADDRESS:1642 Mail Service Center, Raleigh, NC 27699-1642 www.ncdhhs.gov • TEL: 919-707-5874 • FAX:919-845-3972 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 1) The new water supply well shall be constructed of either PVC, steel, or galvanized metal casing. 2) The well shall be located as far as possible from the structure where, depending upon where well rig can actually set up, will possibly encroach upon the 25foot setback, but not be closer than l Ofeet. 3) A preconstruction meeting shall be required with the Catawba County Health Department staff to ensure that the maximum possible distances are achieved. 4) The well will be required to have casing installed to a minimum of 43 feet below land surface or to bedrock, whichever is greater. 5) The well shall be at least one hundred feet from any part of the septic system including repair area. 6) Grout will be required the entire length of the casing from land surface into bedrock. 7) A drill bit with a diameter of at least one third greater than the diameter of the casing must be used to drill the cased portion of the well. 8) Grout must be either pumped into place with the use of a tremmie pipe or pressure method. 9) If a full-length grout is not possible due to site conditions, then a packer-liner must be installed in the well. The liner must extend at least five feet beyond the end of the casing and grouted entirely with a neat cement grout. 10)The well must be constructed outside of any road right of way. 11)A grout inspection must be performed by the Catawba County Health Department. The granting of this variance is for the well location only. It in no way relieves the owner or agent from other requirements of the North Carolina Well Construction Standards including,but not limited to the requirements in 15A NCAC 2C .0113(b)to repair or to abandon any well which acts as a source or channel for the migration of contamination. This approval does not imply sufficient water quality. Further, the approval does not relieve your responsibility to comply with any other applicable Federal, State, or local laws or regulations. If you have any questions regarding this variance, please contact me at(828) 713-3335. Sincerely, John M. Brooks R.E.H.S,MS 2