HomeMy WebLinkAboutWELL-01-2023-187250.TIF Ott yip. ('ATAWISA COUNTY _ _ _.
,Orrt.N 1�„ Public Health Department Subdivision CATAWBA PLACE
1Js I:nvimnmental Health Division PINS 379002654473
Po Box 3R4.25 Government Drive,Newton.Nt' 2t5t 55 t.o I'd 9& 10
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Site Address: 1227 STOWEHILL LN,CATAWBA NC 28609
Name on Permit: REEVES&MICHELLE HILL II
Property Size: Acres 2.1
Directions: Sherrilic Ford Rd,Lowrance Rd left Stowehil:Ln to end
Owner/Authorized Representative Acknowledgement of Permit Receipt
__)(
,
1 I certi Iv 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-I1-2022-42668,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
v Electronic ImageTransmittal/E-mail (Return receipt required)
As the property owner or authorized representative 1 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(ISA NCAC 18A.1900),
and/or Well Construction Standards(15A NCAC 2C.0100), shall apply to the issuance of this permit and
the construction ofthe wastewater system and/or water supply well permitted.
Permit Issue Date: 01/09/2023
Owner/Authorized Representative Signature / e44, t.,tM--
Date /-2-/- ,Z .3.
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by. (name of perswi sending perniil)
Signature _ 0 -- - Date/Time ibebi,3
Method: Fax V 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 yot.Please ttake a few mornentts Ito complette our custtomer service survey att
http://www.surveymonkey.com/s/ENCusttomerService
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WVE1.1.CONSTRUCTION RECORD (CW-1) ' For Internal Use(tnly'.
I.Well Contractor Information:
Robert Teague g 14.WATER%ANFS
Well Contractor NametROM I()
DES(RIPt1OM a
2857-A ;3 ' 'tt' a4 U rt, ) 6,.hpl!"]._
ft, 1 rt.
NC Well Contractor Certification Numhrr
15.C)U I1 H CASINt,(for mWutawd waft)OR LINER(If a &sbN)
B&K Well Drilling Inc ^FROM }r G Ili� 0i,01,Ei R 1111001aS NATFRIAL
Company Nit me 0 ft. ft.�^�E 116 to• ion-21 PVC
.. � � 16.L`._11CASING OR TUBING(geothermal d i •
2,Well Construction Permit N:i� / FROM_ III DIASTE TE13 ta/HICKNs MATERIAL
Lst oil apphrablr well calumet.,pr,ma.0a f'1r-.r'm,nr•..Mar repeal(r.rte) ft. ft. -- --In, _
3.Well Use(check well use): ft.
i R, In.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE fHICK!IIM MATERIAL
pAgncultural OMunicipal/l'uhlic n• i h, in.
DGeothrrmal(Ileattng/Cooling Supply) IDResidential Water Supply(single) '—' ft. ft. in. —'—_ --
IDIndustrial/Commercial ['Residential Water Supply(shared) IS.GROLT
1inigntion _._piths-..1 TO MonStIAL EMPLACEMENT NJ"TTITH/i,lfigtiJri
Non-Water Supply Well: n. n.
0onitonng ORccovcry ft. ——
MInjection Well: _ ^ ____
H. R.
['Aquifer Recharge DGtoundwatcr Rcrncdiation
19.SAND/GRAVEL PACK_(If applicable)
Aquifer Storage and Recovery ['Salinity Barrier FROM I TO MATERIAL
EMPLACEMENT METH(r0
Aquifer Test ['StormwaterDrainage fL ft.
Experimental Technology ['Subsidence Control ft.. ft.
Geothermal(Closed Loop) Di-racerr 20.DAlI,LL TO LOG(awcb additional sheets if ncmuryj
['Geothermal(Heating/Cooline Return) Other(explain under N21 Remarks) FROM t1KRCaIIr710N fmler.y daess seiVrerY t?p.Enla sea aln)
4.Date Well(s)Completes' `a Well IINf R, IL ) � "
Ail-t"1—
, a.Well Location: " (�S C�S.rt.
u v P-S ' i 1 ' c.\t1\c\k4 ft. ft.
\) �l.1(. ��fl
Facility/Owner Name Facility tDl(ifapplicable) ft. ft.
1111 S. CAos..1 e.11N\\ L1\1 II.
Physical Address,City.and Zip ft. ft.
C+�k�t✓/ "\ 21.REMARKS
County ll` Parcel ldcntif'caoon No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )
(dwell field,one ht/long is sufficient) 22.C ifieati
N W / S— _6)3
6.Is(are)the well(s)ePermanent or ['Temporary Signature of Certified W Contractor Date
��ss....��,,//// Ily.vgning this ham,1 herrhi'certify that the'Milts nos(were)constructed in accordance
7.is this a repair to an existing well: ['Yes or RNo i iih/5.4 NCAC 02C.0/on or ISA NCAC OW 0200 Well Construction Standards and that a
if tiro it a repair.fill out known Hell construction mfnrmara,n on splain the nature attire ropy of rhi,record has been provided to the well no der.
repair under N2/remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_______ j S,(LgMITTAL,INSTRUCTIONS
9.Total well depth below land surface: 30 (it-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-2C2th)-and 2 ry1o0'1
construction to the following:
10.Static water level below topof casing:40
(ft•) Division of Water Resources,Information Processing Unit,
If water level i.+ahote easing,use 1617 Mail Service Center,Raleigh,NC 27699.1617
6
11.Borehole diameter: 1/8 (In.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above, also submit one copy of this fomi within 30 days of completion of well
(i.e.auger,rotary,cable,direct push.etc.) construction In the following'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serv-1 c Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Air Flow
method of test; 24c.For Water Sunply& Injection Wells: In addition to sending the form to
Chloe Tabs t ttz tax the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constmcted.
Form OW-I North Carolina Department of Ensironmcntal Quality-Division of Water Resources
Revised:-22.2016