HomeMy WebLinkAboutWELL-03-2023-190668.TIF H,
t
yy • CATAWBA COUNTY
E. AI , , Public Health Department Subdivision
'� Environmental Health Division PIN# 375113024954
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
/8.
Site Address: 2064 CROWN DR, CONOVER NC 28613
Name on Permit: *EVERETT CUSTOM HOMES OF CATAWBA VAL
Property Size: Acres 3.67
Directions: Hwy 16, Right Emmanuel Church RDm Right Travis Rd, Right Crown DR, about 1/2 mile home is on Right
Owner/Authorized Representative Acknowledgement of Permit Receipt
4 _ I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
K, As the property owner or authorized representative, I have received the above referenced
permit(s)as requested in the application for service RBPR-02-2023-43556, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
IElectronic 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: 03/07/2023
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)
7 31) I)3
Signature rl•`
Date/Time
Method: Fax VV f 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 youPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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WELL CONSTRUCTION RFfiURi)(C\V-I) tot Intcrtlal IJse Only' ....
I.Well Contractor lnformatioo:
Robert Teague 14.WATER ZONES _-
WOConnac-torNefic — FNOM 10 Lw ---__ ..___ �_
2857-A I/ ot,sn• p n.___,_�usMRln /am_Ode .-
VC w'rll Cocso ctor Cemftcaoon Sumner ..:I()IL -I�L? it. rJ /1 e
15,OUTER t:ASL -�or alottl-c d`wweJYJ OR LINEA),N apEtlabk)
B &K Well Dolling Inc FROM ki
T DIAMETER TNICA NESS l MA1IIUAL -
Company nameO3 "� -_ a n. ry` n. u it$ in' SOR41 1 avc
2-wJ 7� /'� 1L INNER DR TUBING(EeatMewrl esrM•Map)r
2.Well Construction Permit d: f t/�.S'"7 "'FROM ,.• TO hIANETFRm TNK-Kass MAl[NIAI. -.
Lartail,yy,(�¢Llr+.ellrvvtrrrcnonprrnun r+r 1'/t..(*owrry a 4;rrvnnrr.eft.I
n. ft. T.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIANIETTR : SLOT NILL IHICK\Lit I5rP.M t
0Agncultural 0MunicipalPublie ft. h. in. I
°Geothermal(Heating"Cooling Supply IDResidential Water Supply(single: h. h. I In. i (
0Industnal'Com merctal ORestdenual Water Supply(shared) to GROUT
htmesnon Fwomm To I NAILRIAI ivnita,Ctsavt M[1NO0a\NOI%1_
Non-Water Supply Well: ft. ft.
O'vionitonng ORcvovcn h. n.
Injection Well: f.—
°Aquifcr Recharge Dtisoundwatcr Retncdtatlon n' ft.
f-�Ago fer Storage and Recovery. 19.SAND/GRAVEL PACK_Of applicable)
6„t8 ❑Saimrryl3arner FROM TO MATERIAL C%PLACEMENTMEIHot,
Aquifer Test 0StomwaterDrainage n. n•
13 Experiment al Technology Subsidence Control R h.
°Geothermal(Closed Loop) QTracer 20.DRl21.ING LOG(atraa additkvaal Aetna If aecmrrry) TW
FNON TO I hltKRl F11O%trolot a,N wwl'estan , •da.1o.on
()Geothermal(Heating•'Cooling Return) rlOther(explain under 021 Remarks) Eli n
4.Date W'elI(n)Completed: 1\t I G 3Well tl 4 n.us.. • I. _.r,., -a 5_0_4 ,
Se.Well Location: P a • L ,., • a CA f.I qr.-C-Of444-(-- ii--,
rt
Facility IOR(if a Itcablcl ft. rt.
Faetlny Qwxr Noire �Y �-+�DPP - --
a OLD it OW Al Or. (6 t60 h. n.
Phyzxal Address,City.and Zip ft. ft.
C CAA Qr l 21-REMARKS
Counry S t1�{� Parcel ldcrudicanvn No tPlNl — ---
-
Sb.Ladtude and longitude In degrees/minutes/seconds or decimal degrees: -.....-.._.
(dwell field.one talons is sufficient) 22.(craft n:
N W / ? 1 -/_
%sawn of Crnrfk dl Cunt; r Dec
6.Is(are)the well(s)0Permanent or [)Temporary
$v vitas Au Jura4 I kw-a&rrl a)j that Ow arils's ww iwoYl«ruuwrini in 4.,,•,wn.
7.Is this a repair to an renting well: 0Yel orAlio Kith rJ.l',CAC 02C OIOq a IBA ti'(ACO:C.0200 lYrll Cnasrrvelwn Shlndain . 'rs r.
If 14" u a apes,.fir!out Gown»elf awtruciiun reformationtarn she mules'of air <"p`i,ilia sect"(luau hrrn y n.JeJ iu She wr!/..w err
repay wader a:1 remarks srcnaa or as the trkA of dui Joan 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site dct ik cn »e:
6.For Geoprobm/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 W-1 is needed. Indicate TOTAL NUMBER of wells
conatnicnon details. You may also attach additional pages if necessary.
drilled: f� ��� ,+'UB;►11i'[AL INSTRUCTIONS9.Total well dep—th below land surface: (I) 24a. for All Wells: Submit this form within 30 days of completion ot we': 1
For muttrple oche hit aadep7hr rfdrs ferenr rctamptr-)-g200 mkt I I00'1 construction to the following:
10.Stadc water level below top of casing:40 (ft.) Division of Water Resources,information Processing Lod,
ff wo en lnel u show caw%use 1617 Slail Service Center.Raleigh,NC 27699-1617
II.Borehole diameter- 6 1/8 (Ia.) lib.for Inlection Wells: In addrtial to sending the form to the address in:.t
Air Rotary above,also submit one copy of this form within 30 days of completion ot wci
l2.W'ell eotutruccioa method: constuction to the following
(La eujer.rotary,able,&race push,eta.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLL WELLS ONLY: 163b Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Os Method dust: Ar Flow - 24c.Fur Water Supply .R Injection Wells: in addrnun to sending the html I
the addreas(es) above. also submit one cop) of this form within +0 Soo o
13b.DWnfecdon type:
Chlor Tabs Amooat: 1 1"Lw completion of well construction to the county health dcpatumcnt of the count
where constructed
Form Gu'.I Notch Carolina Depanmcm of Environmental Qua{it)-Drvuwn of water Resourcca Rel'LP:•::•:Oi