HomeMy WebLinkAboutWELL-10-2022-182682.TIF •
49�T& CATAWBA COUNTY Case#
d+ ` Public Health Department Subdivision
3 q,-a t Environmental Health Division PIN# 269902699716
f;1:Y w
# PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 2
Site Address: 5202 DEER PINE DR,HICKORY NC 28602
Name on Permit: *LAUREN& LORENZO DIMAIO
Property Size: Acres 10
Directions: Right off of Pittstown Rd onto Sand Pit Rd. Right onto Deer Pine Dr.Lot at end of rd.
Owner/Authorized Representative Acknowledgement of Permit Receipt
LD I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
i1.7 As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service RBPR-07-2022-41751, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
V Electronic Image Transmittal/E-mail (Return receipt required)
bAs the property owner or authorized representative I have reviewed and understand the specific conditions
r` 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),
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: 10/20/2022
Owner/Authorized Representative Signature
-
..--r 2
Date 1p 1 4-1 i 27
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of'person sending permit)
Signature4g Date/Time /0 bili))
Method: Fax _ 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 yoLPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
a dinnAi0 oil)bes l.am
chpenmi 10/20/2022 15:51
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information: I
NEILL PARDUE
14.WATER ZONES I
Well Contractor Name FROM 10 DESCRIPTION
2609A 689 n 670 n• — — I
n.
NC Well Contractor Certification Number ft.
IS.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)AIR DRILLING I N C FROM TO DIAMETER 'illICKNES9 MATERIAL.
Cutstpan)Name 0 rt. 65 II.J6 in. PVC
10-2022-182682 N.INNER CASING OR TUBING(geothermal closed-coop)
2.Well Construction Permit If: FROM To DIAMETER TureteNE.S. MA
all unpin uh/r well congruity',permits(Lc.I le.Curve lt',Settle.Amami,.err./ n. O. In. -�_
3,Well Use(check well use):
n. ft. In.
Wnler Supply Well: 17,SCREEN
I:\griculuira] FROM TO DI,\n IER ------•
I_IMunicipal/Puhiic SUM sue. uucl:ntss I �I+tr.Rl.�l
n. a in.
(ieulhermal Bleating/Cooling Supply) elltusidcntial Water Supply(single) — i
fl. tY. in.
;Industrial/Commercial I.(Residential Water Supply(shared) .—
flhrigation IS.GROUT ---
❑Wclls>100,000 GPO FROM TO MATERIAL. Ebu'IACEMF.VT SIETIOD&ANIOVNT Nun-Water Supply Well' 0 n' 20 fl' GROUT POURED -
11Monitoring CIRecovcry — _
n. ft.
Injection Well:
— _
I lAquifcr Recharge l7Groundwatcr Remediution rt. n. I
i(Aquifer Storage and Recovery IJSalinity Barrier19.SAND/GRAVEL PACK(if applicable) �I
FROM TO MATERIAL __--_- EMPLACEMENT METHOD
i(Aquifer'lest — ---
[1Stormwater Drainage n. n. --
(7Experimcntal Technology flSubsidence Control — —
t. n. �
(Ificotherinal(Closed Loop) I(Tracer 20.DRILLING LOG(attach additional sheets if necessary) 11
LiGeothelmal(I leating/Cooling Return) (']Other(explain under 1121 Remarks) FROM TO DES(_itlls'rIU\(slur,hanlaess_soiUrvek iypr.gr.insite.rot.)_
0 n• 55 n• DIRT
4.Dale Well(s)Completed: 02-08-2023 Well Ina 55 n 705 n• ROCK -� I
5a.Well Location: ft. ft.
HICKORY WELL — n.-"" n - — — —
Ia..is v+v(In Nam.- Facdrty IDdittiapphcablel rt. n• ------ - ---- -- - - -1
5202 DEER PINE DR,HICKORY,N.C. 28602 n: 1 ft. i
Physical Address.City.and Lip ft. ft. -
CATAWBA 269902899716 21.REMARKS ---County Parcel Identification No.(PIN) ~
5b.Latitude and longitude in degrees/minutes/seconds or dedmal degrees:
Or well field,one iat/lung is sufficient) 22.Cer'ti I' Q
35° 38.987 N 81° 21.926 W ��JC. /9ctitchtz.
2/8/2023
6.ls(are)the well(s): ('(Permanent or rnl•empurary Signature or Certified Well Contractor note
By Aigning this limo.1 hereby t'Clilly Alt the WellItt war furred erratum ted IN ar,unhurt -,n:r
7.Is this a repair to an existing well: t:lYcs or i'INn 15.4.1(:4('oic•.01011111.15,(N(a(-a]C Jelin Wet/C•onrn'Ncman Skint/..;!,omit r)nn.,•,.1.,
II ilm is a repair.Jill out known well c'a,o rn7ioa ie;Jbrwtatioa and eaplaln the nature Waite u/this record hose been pram/rd to the writ saner
repair ornler If]1 remarks section or no the bark°I'thir%urea.
23.Site dingrant or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction roll,8.
(add'See Over'in Remarks(Sox)-You may also attach additional pages if neccssai).
construction,only I(iW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft.)
i ia-nuibgil',roll./i.r all r/rptln ifdi/(,'rent(example 3.1'uu'�nnl''0 MITISubmit(his GW-1 within 30 cloys of well completion per the following:
I11.SlRtic outer level below lop of casing: 60 (fl,) 24a, Fur All Wells: Original form to Division of Wilier Resources (MR).tr danr/ei,li+nbnrrtu„nr.use ," Itiinmaliun Processing Unit.1617 MSC',Raleigh,NC'27699.1617
24b. For Injection Wells:Copy to 131\rR, Underground Injection Control(il.(:1
I I.liurcholediameter: 6 (in.)
Program, I 636 MS(',Raleigh.NC 27699-I636
12,Well construction method:
li:c.auger,rotary,cable,direct push,etc.) 24e.For Witter Supply and Open-Loup Geothermal Return 1Srlls:Copt Io the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWI(,C'CPC'l In
138.Yield(gpm)6 Method of test: AIRPermit Program,1611 MSC.Raleigh.NC 27699-lo1 l
13b.Disinfection type: HTH Amount:
hunt,(iW-1 North Carolina I)ep,o Intent of Pm inmmental Quality-Division of Water Resources
Riivtscd t»o-•uls