HomeMy WebLinkAboutWELL-12-2022-185887.TIF . r
�'W4'. T CATAWBA COUNTY - -
( Public Health Department Subdivision
�_ s Environmental Health Division PINS 269902751449
111b, PO Box 389,25 Goveniment Drive.Newton,NC 28658 LOTS B
Fait
Site Address: 5476 WHITENER RD,.HICKORY NC 28602
Name on Permit GREGORY SMYRE, II •
Property size: Acres 26.88
Directions: NC10 bear left onto whitener rd,property on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
_4certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the propertydescribed above.
ll "As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-09-2022-42245,by the following method(s):
Received in Person
_ Facsimile Transmittal(Return form with signature required)
J Electronic Image Transmittal/E-mail (Return receipt required).
V4sCproperty 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),
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: 12/08/2022
• Owner/Authorized Representative Signature 127 __�'s �
Date J �,,,.d-1
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time 11/4.4?3
Method: Fax J Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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Parcel: 269902751449, 5476 WHITENER RD 11n=200ft
HICKORY, 28602
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to ensure the accuracy of location and labeling Information contained on this map or data on this report.Catawba County promotes and recommends
the Independent verification of any data contained on this map/report product by the user.The County of Catawba.its employees,agents,and
personnel.disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct.indirect or consequential which arises or may
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Copyright 2021 Catawba County NC
1
WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES -
WellContractorName FROM 'CODESCRIPTION
3254 A 100 ft. 1025 ft.
It. rt.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(If ap lieable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 f° 59 ft6.25 i"• SDR21 PVC
WELL 12-2022-185887 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit ft: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e U/C'.County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. It, In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(I leating/Cooling Supply) OResidential Water Supply(single) ft ft ' in '
❑lndusttial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑Irrigation [Wells>100,000 GPD FROM TO MATERIAL FMPI.iCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ff. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Slormwater Drainage ft. ft.
['Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach addidonal sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Oilier(explain under 1121 Remarks) FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
0 R. 54 ft. Dirt
4.Date Well(s)Completed: 9-2-2023 Well ID# 54 ft. 1025 ft. Rock
5a.Well Location: ft. ft.
Gregory Smyre, II ft. ft.
Facility/Owner Nome Facility ID1i(if applicable) ft. R.
5476 Whitner Rd, Hickory NC 28602 ft. ft,
Physical Address,City,and Zip ft. ft.
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) 22, ertitication:
35.674.73' N 81.403.42' W
�J 9/13/2023
6.Is(are)the well(s); nPermanent or ❑Temporary 'attire of Certified Well Contractor Date
Sr signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15.4 NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction htfis nralinn and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or an the hack of this four.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only l OW-] is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
dri I led: _
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1025 (ft.)
For mteltiple wells list all depths if different(example-3(0,200'and 24!100') Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 00
(ft 24a. For Al] Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(lUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
(i.e.auger,rotary,cable.direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to 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 DWR,CCPCUA
13a.Yield(gpm) 2 Method of test;
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount; 3 Cups
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018