HomeMy WebLinkAboutWELL-02-2023-189321.TIF CATAWBA C011ir-T)' Case# WELL-02-2023-189321
sPublic Health Department Subdivision
,' Environmental Health Division PINii 372513137171
„if PO Box 389.25 Government Drive,Newton.NC 28658 I oi#
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Site Address: 4715 16TH ST DR NE,HICKORY NC 28601
Name on Permit: ROBERT AND KELLY HIGHLAND
Property Size: Acres 9.51
Directions: McDonald Pkwy NE.road changes to 24th St NE,bear left onto 29th Ave Dr NE,right onto 16th St NE,right
onto 16 Street Dr NE,turn left
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the pmperts described above.
As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service EH PR-02-2023-43374,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(I5A NCAC I8A.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:02/15/2023
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 Date/Time ID1//)3
Method: Fax 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:372513137171,4715 16TH ST DR NE tin=60R
HICKORY,28601
This msphepaf product was prepared from the Catawba County,ty,NC Coosps4l Information Services. Catawba County has made substantial snorts
to ensure the accuracy of location and labeling Information contained on this map or data on this report Catawba Courtly promotes and rsconvnends
the Independent rerflkaion of any data contained on this map/report product by the user.The County of Catawba.Is employees,agents.and
personnel,disdain and shall not be held labia for any and al damages,loss or Nabety,wM4w*act.Indirect or consequential*filch arises or may
arise from this map report product or the use thereof M Copyright person or Catawba County NC
02J15/2023
WELL CONSTKUC'1'ION RECOK1) (GW-1) For Internal Use Only:
1.Well Contractor Information: I
RANDY OWNBEY
14,WATER TONES
Well Contractor Name FROM TO DESCRIPTION
.-
3214A 189 ft, 200 rt.
NC Well Contractor Certification Number --
rt. ft. '-
AI R DRILLING INC 15.OUTER CASING(for multi-eased wells)OR LINER(if ap Ileable)
FROM TO DIAMETER TIIICKNEss MAIERR1.
Company Name
0 ft f 88 ft. k
in, PVC
02-2023-189321 t6.INNER CASING OR TUBING(geothermal closed-loop)
2.Wc11 Construction Permit ; FRVMI TO DIAMETER TIIICKNES$ VI1TER111.
Lott rill uppbeahle well construction permits(i.e.U/C,County,Suite, Variance,etc) fL ft. In.t.
3.Well Use(check well use): - ft. ft. -in. - "-
Water Supply Well: 17.SCREEN -
IJAgTICultuttd FRUMI TO „ DIAMETERDIAMETERSI.OT SIZE THICKNESS _ N!A_IY:RIAI:UMunicipal/Public ft. ft, in. —
i dictnhernlui(l lealntg/Cooling Supply) I'IResidential Water Supply(single) r_� — — --
ft. f ft. in.
I'industrial/Commercial I IResidential Water Supply(shared) -
ta,GROUT
!Irrigation I-1 Wells? 100,000 GPD FRUMI TO MATERIAL EMPLACEMENT METHOD&AM1IULvt•
Nan-Water Supply Well; 0 ft. 20 ft. GROUT POURED
liM IY rt. rtt--_ -onitoring DRecove - --------
n.
Injection Well:
I lA alter Recharge n- ft.
9 g LlOmundwatcr Remediation
I(Aquifer Storage and Recovery L'ISnlinily Barrier19.SAND/GRAVEL PACK(if applicable) -
FROM To SIATERl.11• EMPLACM:MENTMl:'fBUD_
I lAquifcrTest UStommaler Drainage ft. ft. -
❑Eixperimental Technology flSubsidence Control rt. ft.
1'Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
()Geothermal(I lealing/Cooling Return) ClOther(explain under f121 Remarks) mom TO _ DESCRIPTION(color,hardness,solUrock type,grain axe,etc.)
(s)Cora p 03-16-2023 0 It 178 ft DIRT
leted: Well IUS --"_..-._. -_4.Date Well
78 n• 205 n• ROCK
Sa,Well Location: R. ft. -_._-..-_______ . -
ROBERT HIGHLAND n. ft. --
fac.hq:(iwner Name Facility IDa Of applicable) ft. fl. - .
4715 16TH ST NE,HICKORY,N.C. 28601 ft. rt, ----
u)•4.r.A,Idrt,>.l d).and lip ft. ft. --
CATAWBA 372513137171 21.REMARKS
(t ant) Parcel Identification Nu.(PIN)
—
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field.unc lot/long is sufficient) 22.Cel't Op: _~—
35° 47.902 N 81° 17.263 N, 4..4.
� 4
3/17/2023
6.Is(are)the well(s): PJPermanent or OTemporary Siglmtutu of Certified Well Contractor DII1e
Designing this form,t hereby cart/l.(•that the well(s)inn(were)constructed in uecordume with
7.Is this a repair to an existing well: l7Yes or PIN° !SA NC-IC 02C.0100 or 15A WA('02C.0200 Well Construction S:wtdwrts and that a rapt
1/')hit it a repair,MI out known well construction inlitemulion mend explain the none ul the (i/'rh/s re,vmd line been provided to the well owner.
repair under n21 te»rorkt.section or on the hack of this fitrnt.
23.Site diagram or additional well details:
R.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Ovcr'in Remarks Box).You may also attach additional pages if nefxssar).
construction.only I C)W-1 is needed. Indicate TOTAL NUMBER of wells
drilled: -- --
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (fL)
tiemu/riplr week list all depths j/'dI/%crept(example-3(+200'and 21,01o0') 5ubmil this GW-1 within 30 days°f well completion per the following:
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
111.Static water level below lop of casing: 50
1r,,,ran/rr,d„aln,r,•,,ettn,4.u.,•••• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
2-lb. For Injection Wells:Copy to DWR.Underground Injection('antral III-( t
11.Borehole diameter: 6 (in.)
Program, 1636 MSC.Raleigh.NC 27699-1636
12,well construction method:
n.c.auger.wtary,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 in:,tnlled
FOR WATER SUPPLY'WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPC'U,\
13a.Yield(gpm)30 Method of test:AIR Permit Program,1611 MSC',Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
form(2W-I Nomiti Ca,arlinrw Department of Environmental Quality-Division of Water Resources
RcYl,ed tw-M1-:,nI>•