HomeMy WebLinkAboutWELL-11-2022-185015.TIF act a CITAWBA COUNTY
Public ficatth Department
�✓1 Subdivision WYNSWEPT PH 5.'
,i, .� yi Environmental Ilealth Division f9Nk 367804626568
�\/if PO Box 389.25 Govcmmcnt Drive.\c»ton.NC' 28658
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Site Address: 3159 TIMBER RUN LN,MAIDEN NC 28650
Name on Permit: 'NEST HOMES LLC
Property Stu: Acres 0.73
Dtrectiona: Intersection of Buffalo Shoals Rd and NC 16 S;NC 16 S to Left on Cayton Or; Left on Timber Run Ln
Owner/Authorized Representative Acknowledgement of Permit Receipt
4,4°1 certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
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the property described above.
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As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service RBPR-08-2022-41897,by the following method(s):
Received in Person
T Facsimile Transmittal(Return form with signature required)
Electronic Image'lransinittal/E-mail (Return receipt required)
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.1 900),
and/or Well Construction Standards(1 SA 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: 11/23/2022
Owner/Authorized Representative Signature L P.C. -41-71.,.."----
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Date 1,9-/b /d—D 3,-'Z
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by /Hume of person sending permit)
Signature Ci_E [)ate/TimeJ)/lI/77
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 yozPlease ttake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkev.com/s/EHCusttomerService
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'Print Form I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ..
1.Well Contractor Information:
Michael A Brook 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 130 ft. 20 gpm
4210A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)"OR LINER(if ap licable)
Rockwater Well and Pump FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 101 ft. 6.25 in• SDR21 PVC
WELL-1 1-2022-18501 5 16.INNERCASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 Municipal/Public 0 ft* ft. in.
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Bentonite 16 bags
Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge IDGroundwater Remediation 19.SAND/GRAVEL PACK(if appticable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft 60 ft• red dirt
4.Date Well(s)Completed: 11/4/25 Well ID# 60 ft 90 ft. lensed soft rock
5a.Well Location: 90 ft 160 ft dark blue rock
Nest Homes LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3159 Timber Run Ln Maiden 28650 ft. ft.
Physical Address,City,and Zip ft. ft.
Catawba 367804626568 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 11/15/25 •
6.Is(are)the well(s)1 Permanent or jTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C.0100 or ISA 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 copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
23.Site diagram 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 site details or well
construction,only 1 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: 160 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 63 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61/8 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
air rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,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) 20 Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1.5 lb completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-'Division of Water Resources Revised 2-22-2016