HomeMy WebLinkAboutWELL-12-2022-186423.TIF .1yi�. CPATAWBAl COUNTY
13: .f. , , Public Health Department Subdivision FAIRWAY ACRES
,"L '��, Environmental Health Division PIN 372017021060
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 5
/8 2 w
Site Address: 2988 QUAIL DR, NEWTON NC 28658
Name on Permit: *J&M PROPERTY INVESTMENT LLC
Property Size: Acres 0.58
Directions: Startown left Sandy Ford, Left Chestnut, Right Rosewood, Left Fairway, Right Quail Dr
Owner/Authorized Representative Acknowledgement of Permit Receipt
pi( I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-10-2022-42477,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 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: 12/20/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending
permit)
Signature E Date/Time f/j i l
Method: Fax f Email US Mail 1 Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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ehpermit 12/20/2022 15:10 r
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Garrett Clause �5 r -AA'• � �'^0 4..kti z>r
KC TO DZsoRIPTION •
gleJlConlzaotorDlamo • ..off, LL ft
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11CwoA Conhaator CortiiioationlTwnbec • getri f 0-30)Y1 .-..m- 1r0 Y 71s)1b)WA'" "fire k: k^;. ': Yv'. • .
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ate. ft' • � i % a `fig �• s PVtiA v v ,
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2.Well Construcftou 1,emit# ln/ `_to•'-'�ZV-IpCMori[ To 7arAnrgTZx IMICAMESS Mg7[EttzAT,
.41stall applicable-well consdFotlonpermits(re.VIC,County,State,Variance,eta) it.
It. ft: In.
3.WellIfse(eheckwalluse):
Water Supply Watt: a ztonx To nrAMETER aLOT SIZE _ THCC8Si6S9 ri3A TF1xrAs _
Agricultural '
aMwueipalRublie • ft. In.
(Heating/Cooling Supply) 1 :esidenfial Water Supply(single) ft. is in.
lndustrial/Commexoial MIResidential Water Supply(shored) f •b�3 syt0.}=YrV - x t
i.
ligation OW PROM TO ISrAT 5Idx+ S82Y7�ACENFENC OD&AMOI1f1T
Ic;aa.-Water Supply Well: . . 1 ..it: ' ft, 4C VV,,
Monitoring Recovery ft. ft.
Need=Wall: f4 ff.
011Aanifer OGroundwaterRemerliation MtDI .F pp knb11e0" GfiS sn,•}
(Aquifer Storage and Recovery . Ogslmity.BBII s PROM TO MA Y4117140B'N31TMETI{OD
�J Aquifer Test DIStormwaterbrainego ft. it'
ri$xperimenfslTechnology lafSabsidenooControl ft. It: i ••
R
Geofhemlal(ClosedLooD) Mauer *u A ocyx•-�a'ibTarnWaalah'Qf t satbVe SMa:-L •:i?
rem To nnso Tencat(ecTn,hardaus.soillmcktype,grain size.efe.)
Geothermal(Heaimg/CpolingReturn) alOther(explaintnder#21 Remarks)_ U ff. f #t ' . �rt-
4.Date Well(s)Completed:124�'7`k Wenp# T.ft. ) ft 13,r,,,,,„ '. .,,cA' • '
L) ft. bsr ff. Pto�y k-
Sa.WellDocatian: G 32o ,ey
,J '� `ia / i'�tk1R f`LLn �y r J{ t n.
Facility/Ow�lner27amo Poa:lityID#(i`fapplicablo) 110 ‘C7 S 1✓+L. f4)ea 1
27O g Q-'c \ �f /L tv e. • r'ft. 20 ft. 4-j1 t•e C9Ir'e.l Me-.
1'hysioal.Address,City,and Zip I j�//� j I j� -T ICIt' 'O ) ?'. ( /._( 2 f4 i 4. ._
b ic>bo ti�
County . PaIcalXdcntifcaiionNb.(PM I
.I
5b.Latitude and longitude fn degrees/minutes/seconds or decimal degrees:
(ifwell geld,one iaNlonges suit oient) 2.2,Cextiticatiou:
S65-se22`l t`,2 gq C.9. . W DrCeelel
i- v 202
• 6.Is(•are)ilia•Wal1(s)irk•exmanent or ]1Ternporary SigoatuaoofCertifiedy;rellConixaotor Rate
By signing thfr form,I hereby nerd;'that the well{s)woe(were)constructed i a accordance
7.Tells a repair to an existing welt: Wes or *No • with 154It•OAC 02C.0100 or 15ANC4C 02C.020017ell Coruirucfan aandm ds and gat
7fthtsisareport, illoPtlrtown well earlsimetianWormation and ec,plain the nature erne "IV ofihicrecord has berg provldedto the wellomen
rapa;r rotdertt2l remarla section or on thebackafthi dorm. 23.Site diagram or additional•Stall details:
8.Tor CYeopxol e/DPT or Clnseril0op Geothermal W ttehavingthoname You may Imo the back of this page to provide additional well site details or well
- construction,only IGWxis needed.Indicate TOTALNUivIBBRdwells construction details.You may also Attach addifionalpagesifnecessary
drilled: SUBIVIITIAI,INSTRUCTXONS
9.Totalwelldepthbelowlandsurface: 00 (ft) 24a.gor All Wells: Submit this form within 30 days of completion of well
For mulbplewellsUstalldapthsi}'aVercnt(ecample•AN200'and2(0700)rr construction to the following:
10.Statiew IteCI )aterlevelbelowtopofcasing: V (ft) Division of Water Res eure es,Xnfoxmationlraees sing Unit,
.If1Yaterlevel it above coring,use"•1•" Ito 1.6X7 Mail Service Center,Raleigh,NC 7,7699 x617 ,
11.Borehole diameter:• gal) 24h.,wor Tilted-ion Wells: 1g addition to sending the form to the address in 24a
l 'above,also submit one copy of ibis fonm within 30 days of completion of well
12.Wellconsixuctionmetkod: rr oonstrucfionto the f'ollowing:
•
(La.auger,rotary,cable;acetyl).*aim) 1
Division of Water.Res names,Undexground.Xnjeettorl Control X'rogram,
FOR WATBRSTJPPI.2 WW,I,ISONLY I636 gag Service Center,Raleigh,XtC27fi991636
•
13a.Yiald(gpxu) Method offeet: /1 {�C T ce `-i c— 24c.gor Water Smmly&7niectloxt Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13p.Disinfection type: ei/1�1 NI' Amount: completion.02 completion•of wall conatzucfon to the county health department of the county
whereponstruoted,
FonaGW--1 Mel.CarolinapepartmentofBnviranmentalQaality-Division of Water Resources Revised2.22.2016