HomeMy WebLinkAboutWELL-03-2023-191463.TIF 4 !
• CATAWBACOI'NI
t ii
Public Health Department Sutxtnism W ism PH 2
er Environmental Health Division I'lNf1 367804622244
PO lion 389.25 Government Drive.Newton,NC' 28658 LCYfir 40
Site Addr ss: 4525 NORTH WYNSWEPT OR, MAIDEN NC 28650
Name on Permit: MODLIN CONSTRUCTION INC
Property Size: Acres 0.71
Directions: Hwy 16 S Towards Denver,once pass Buffalo Shoals intersection,Wynswept on left
Owner/Authorized Representative Acknowledgement of Permit Receipt
X __ I certify that I am the owner or authorized agent;owner's authnriiation required)representing the owner of
the property described above.
XAs the property owner or authorized representative, I have received the above referenced
fi as requested in the application for service RBPR-12-2022-43086, by the following method(s):
ceivcd in Person
Facsimile Transmittal (Return form with signature required)
1 Electronic Image Transmittal!E-mail (Return receipt required)
iAs 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(I SA NCAC 18A.1900),
and/or Well Construction Standards(ISA 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:03/16/2023
. :::::..4.4.1N_____________
Owner/Authorized Representative Signature
.'1 Date 3/Z ..ZP ...
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name n/'person sending hermit)
Signature _ .2 Date/Time )3 f)3
Method: Fax Y 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 yoaPlease ttake a few mornentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/DiCusttomerService
b pi)od 1,n ice n Cf;m
�f
d pcm° ai
i .lr 2u'3 15 25
I Print Form •
WELL CO\STR1•C7.10\ RECORD (G11-11 F,u Internal 1:sr.Only: '
1.1%ell Contractor Information:
Robert Teague i .WATER ZONES
l._._. _
--_-- ------ lHIH1 Ip 11laCNIrIIO�
wd't Lcr:aCcr\arse -3 ___.—.._.r_
7 n. r/6 ft.
2857-A �6 U �.rzi-,7n' -- —
\C's'r'ICo^never(Cmtfcahcn\uchew .2lb Oh. .-7On. l eeN
L 15.(Jul Elt CASING(for o ltr•ca"sed nets OR LINER if a ble
B & K Well Drilling Inc ' fNU%I TLI_____iJ DIAMETER THICKNESS MATERIAL
i D ft L r1 ft' 6 1,6 In. Sbn.21 1PIC
Compass mane , �v
�1 '7 16.11•NER CASING OK I UBING(geothermal elosed-loop)
2.Well Construction Permit n:c7`•6.3' -- 1 4 1 .wmn 6 3 t•It1N I TO t DIAMETER THICK% O0 J MATERIAL
—
Lruat app:e:ab4“r9,„c,vu,a.•::v.mgc, r I4.. (.01 A•Stak, ,r.rir1 L� f(i. (l. Co.
}
3.Well Use(check melt use): It. ft. In.
1
Water Supply Well: II.SCREEN
FNOM TO h, Di%IFTl,N SLOT St7.r. THICK�CR.e MATERI AI.
.Agacultural QSfutut:Ipai,Puhltc fr. rt. In. j
Geothermal(Heating Cooling Supply) ®Residential 11ater Supply(single) —
ft.-.
t.~ in. i
fnduotnal Commercial DResldenUai Water Supply(shared)
PiImganon Ifs GROUT _FNUM TU _ 1 SIATLRIAL EiIPL ACEstEssT METHOD&A 401.NT
on-Water Supply Well: rt. l rt.
Monitoring oRecosery ft. rt.
injection Nell:
Aquifer Recharge
_
•c ft, ft.
�Groundwatcr Rcmcdtauon
Aquifer Sto erne and Recovery 19.SAND/GRAVEL PACK Of app Leable)
�S211n 1(y'Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage fl rt 1
JExpenrnentalTechnology OSubstdenceControl ft. ft. I
Geothermal(Closed Loop) :aver I0.DRILLING LOG(attach addidooat sheep if necessary)
.�1i FROM TO T D. CRIFI 10s Osier,hardneu mama ripe.Lelia sem end
Geothermal(Heating Cooling Return) ❑Other(explain under ell Remarks)
1 ' o n. l ti a tr. i.r 4.. 4 ck�
I.Date Well(s)Completed - —� Well Ulu
0 it. a rt. fir.
�. aJ G(.- �rc,r��rt�
,5a.Well Location: p C,5' ft.3Q.j/..uA _S
1)c n• COf-TrbiT j 0 3vSft. �bS it. iI L t 1r-.zej Xi I,
Facibry:0wncrName I'aCIIc ID*(if apphcabkl rt, rt. i
ysas Nor+k win c,Jep7 O ft.
Physics.Address,CO.and Zip ft. h. it
t r aZT1( 2/ •A I 21.REMARKS
CCouun/q�LASr�� ✓1 Parcclidcnntica:lonSo t PIN I _.-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ufwdl 5dd,one lat long is safficicnt)
1. titic
• 5- I — "I3
6.Is(are)the wells) Permanent or OTemparory' Signature of Ccndicd w;ll t Date
[ti tign:ng ihir httIn 1&nen.'cetrffo:hat the twilit) sac 1'slot asultcleJ In ucevrdw e
".Is this a repair to an existing well: }'es or No tirh 15.4.'CAC 62C 01011 or 12A\'CAC 0:C 0:00 Well Cnnsrrucriea S:urndards and that a
if Mu a a repair.pout k.notn bell eaa.Rry:ton in/nrn4Ltnn nd plain'he Milli,I'•,l Mr cups;/the,moll ha;her"pruvulyd la the sell uwnn.
repair under 021 remark,s Orion or on the Dock of this/orm
23.Site diagram or additional well details:
8.For Geoprobe'DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pros ide additional well site details or well
construction,only I G '-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
y� ';(BVIiTTAl,INSTR�'CTIO\S
9.Total well dep h below land surface: 4L/V,S (R•1 2Ja. For All Wells: Submit this form within if) days of completion of well
Far multiple well;tut all depncc if different rtxampie-3 u_00 aria:3111ri'l construction to the following
10.Static water level below topof casing: 40
g: at.) Di,ision of Water Resources,Information Processing Unit,
!/water level„aho,r rams Ice'- 1617 Mail Sersice Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 1/8 (in.) 2.11).for Injection Hells: In addition to sending the form to the address in 24a
Air Rotary above,also iubmit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following
(i.e aster.rotary,cable.direct push.etc)
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLYr WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield()pm) lQ >lethod of test: Air Fluw 24c. For%Suter Supply & injection Wells: In addition to sending the form to
Chloe Tabs I ,2 os the addressiesi abuse. 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 constructed.
Form CW-1 North Carolina Denan,,c-t of Erg!ronnxn:al ,Quality•Ol,is+an of Naicr Rnaurns Rc+ucd 2•.+Z 2016